ERCP-associated infected intrahepatic pancreatic pseudocyst.

INTRODUCTION: Pancreatic pseudocysts are abnormal mature collections of pancreatic fluid that can develop in association with acute or chronic pancreatitis. Here, we share the discovery of an infected hepatic subcapsular pseudocyst of the pancreas causing septic shock following endoscopic retrograde cholangiopancreatography (ERCP). PRESENTATION OF CASE: A 55-year-old woman with ethanol-related chronic pancreatitis and biliary stricture was transferred to the ICU for hypotension 8 hours following ERCP. Examination revealed mild right upper quadrant tenderness without sign of peritonitis. Laboratory studies were notable for leukocytosis (14.6 k/L) and slightly elevated serum lipase (489 U/L). Abdominal CT scan revealed a previously undescribed subcapsular fluid collection. She underwent CT-guided percutaneous subcapsular drainage with return of opaque yellowish fluid. Fluid analysis showed elevated lipase of 62,901 U/L with cultures positive for ESBL Escherichia coli, Streptococcus constellatus, and Enterococcus faecium. DISCUSSION: A majority of pancreatic pseudocysts develop in peripancreatic regions, while, in a recent study, over a quarter of cases were found in usual sites. The management of subcapsular pseudocysts has not been standardized and often involves endoscopic or percutaneous drainage. Operative intervention is reserved for severe infection or rupture in patients with intrahepatic pseudocysts. Rarely do subcapsular pseudocysts become infected. In this case, we postulate the pseudocyst became seeded by bacteria during ERCP resulting in infection and then sepsis.
CONCLUSION: This case report highlights an atypical presentation of pancreatic pseudocyst as well as a rare septic complication of ERCP.

A 55-year-old woman with ethanol-related chronic pancreatitis and biliary stricture was transferred to the ICU for hypotension 8 h following ERCP (Endoscopic Retrograde Cholangiopancreatography). She was originally admitted for acute cholangitis and underwent ERCP for exchange of an occluded common bile duct stent placed 4 months earlier. After the procedure, her abdominal pain briefly resolved, before worsening with associated diaphoresis and hypotension. She had mild right upper quadrant tenderness without sign of peritonitis. Laboratory studies were notable for leukocytosis (14.6 k/L), 1.5 g/L decrease in hemoglobin level, and lactic acidosis (2.6 mmol/L) with slightly elevated serum lipase (489 U/L). Abdominal CT scan demonstrated a previously undescribed subcapsular fluid collection (Fig. 1). The patient was empirically started on vancomycin and piperacillin-tazobactam and ultimately required vasopressor support. CT-guided percutaneous subcapsular drain placement resulted in drainage of 1.5 liters of opaque yellowish fluid. Fluid analysis showed elevated lipase of 62,901 U/L with cultures positive for Escherichia coli, Streptococcus constellatus, and Enterococcus faecium.

Fig. 1

CT Abdomen showing a large hepatic subcapsular fluid collection compressing the right hepatic lobe.

Pancreatic pseudocysts are abnormal mature collections of pancreatic fluid that can develop in association with acute or chronic pancreatitis. Although they are most commonly found in peripancreatic regions, they may occur in extrapancreatic locations throughout the peritoneal cavity and the mediastinum [1,2]. Here, we share the discovery of an infected hepatic subcapsular pseudocyst of the pancreas causing septic shock following ERCP. It highlights an atypical presentation of pancreatic pseudocyst as well as a rare septic complication of ERCP. At present, the mechanism by which subcapsular pseudocysts develop is unknown. In a recent review of available case reports, a proposed mechanism is that pancreatic secretions slowly erode through the hepatic capsule [3]. Intrahepatic subcapsular pseudocysts most frequently occur in patients with chronic alcoholic pancreatitis. Patients generally presented with nonspecific abdominal pain and were diagnosed via CT [1]. The management of subcapsular pseudocysts has not been standardized and often involves endoscopic or percutaneous drainage. Operative intervention is reserved for severe infection or rupture in patients with intrahepatic pseudocysts [1]. Rarely do subcapsular pseudocysts become infected, with only a few case reports available in the literature. In this case, we postulate the pseudocyst became seeded by bacteria during ERCP resulting in infection and then sepsis.

Author Statement

All of the authors cared for the patient during her hospitalization. After our decision to write up the case report, N.A. gathered and summarized the patient’s clinical information. N.A. and L.L. subsequently reviewed and summarized the data from previously published cases, and together drafted the manuscript. J.K. critically reviewed and revised the manuscript. Three authors approved the final draft of the manuscript.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.