Hemorrhage, Fistulization, and Rupture: Management of a Cascade of Complications from a Single Pancreatic Pseudocyst

Although individual complications of pancreatic pseudocysts are well-documented, the occurrence of multiple complications from a single pseudocyst is exceptionally rare. This report illustrates the surgical management of a cascade of life-threatening complications arising from a single pancreatic pseudocyst of gastric fistulization, intraperitoneal rupture, and splenic involvement following intracystic hemorrhage. A 42-year-old female patient with chronic alcoholic pancreatitis and a known pancreatic tail pseudocyst presented with severe abdominal pain and emesis. The workup revealed active extravasation from a splenic artery branch that was managed with arterial embolization. The patient returned three days following embolization with sepsis and peritonitis. An emergent exploratory laparotomy revealed an infected hematoma and intraperitoneal rupture of the pseudocyst that had fistulized into the stomach with splenic involvement, requiring a distal pancreatectomy, splenectomy, and wedge gastrectomy. Postoperatively, the patient's nasogastric tube (NG) perforated the suture line, necessitating further repair, but she otherwise recovered uneventfully. Arterial embolization can achieve hemostasis in cases of hemorrhagic pseudocysts, but patients remain vulnerable to further pseudocyst complications. Definitive management involves drainage or resection. The management of ruptured pseudocysts should be determined based on patient stability and involvement of surrounding structures.