Images in Clinical Medicine

Rupture of a Pancreatic Pseudocyst into the Duodenum

Hideyuki Hiraishi, M.D., and Akira Terano, M.D.

N Engl J Med 1999; 340:1411May 6, 1999

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Article

Figure 1 A 42-year-old man who had consumed approximately 180 g of alcohol per day for 22 years was admitted to the hospital with acute pancreatitis complicated by a pseudocyst. On the second hospital day, blood was aspirated through an inserted nasogastric tube, and emergency endoscopy demonstrated rupture of the pseudocyst into the duodenum. Computed tomographic scanning of the abdomen with intravenous contrast medium showed a large, walled-in collection of fluid around the pancreatic head (arrows in Panel A) and scattered areas of high density within the pancreatic head, indicating hemorrhage. Upper gastrointestinal endoscopy showed a large, fistula-like orifice (arrow in Panel B) just above the supraduodenal angle. Recurrent hemorrhage from the ruptured pseudocyst was controlled by endoscopic treatment with thermocoagulation. Thereafter, the orifice was gradually covered by the re-epithelialized duodenal mucosa, with closure verified by endoscopy on the 30th hospital day.

Hideyuki Hiraishi, M.D.
Akira Terano, M.D.
Dokkyo University School of Medicine, Tochigi 321-0293, Japan