The Journal of the Arkansas Medical Society Med Journal Feb 2020_Final | Page 8

Case Study
by Jagpal S. Klair, MD 1 , Rayburn F. Rego, MD 2 , Mohit Girotra, MD 3
1
Division of Gastroenterology and Hepatology, University of Iowa Hospitals and Clinics (UIHC) Iowa City, Iowa
Division of Gastroenterology and Hepatology, Central Arkansas Veterans Healthcare System (CAVHS) – John McClellan VA Hospital, Little Rock, Ark.
3
Division of Gastroenterology and Hepatology, University of Miami Miller School of Medicine, Miami, Fla.
2
Intramural Pancreatic Pseudocyst Presenting as
Gastric Outlet Obstruction Concerning for Gastric
Malignancy: Piecing the Puzzle
G
astric outlet obstruction (GOO) is a
clinical syndrome comprising epigas-
tric pain and post-prandial vomiting,
often due to mechanical obstruction. 1,2
Compression by intramural pancreatic pseudo-
cysts (PP) resulting in GOO is a well-defined phe-
nomenon. We present the first reported case of
GOO secondary to pancreatic fistula leading to an
intramural fluid collection of the pylorus.
A 54-year-old man with recent cholecystectomy
presented with non-bilious emesis lasting four
days. Patient endorsed outside hospital admis-
sion for similar complaints four months ago, but
experienced spontaneous symptom resolution at
that time. He had hypoactive bowel sounds but
otherwise non-tender, non-distended abdomen.
Routine lab work was unremarkable. Computed
tomography (CT) without contrast described py-
loric heterogeneity and gastric distension, and a
possibility of gastric malignancy causing GOO.
EGD revealed ballooning around the pyloric open-
ing, raising a suspicion for circumferential pylor-
ic channel tumor (Fig 1) . The scope could not be
advanced further. Endoscopic ultrasound (EUS)
demonstrated a hypoechoic pyloric lesion con-
fined to the deep mucosa (Fig 2) . Fine needle aspira-
tion (FNA) yielded dark fluid, the analysis of which
showed high amylase (>75,000 U/L). There was
one enlarged peri-gastric lymph node, FNA of
which was negative for malignancy. Repeat CT
with contrast disclosed a 2.4x4.5x5.7cm fluid col-
lection around the pylorus with communication to
the pancreatic duct (PD) (Fig 3) . Fluid collection was
drained endoscopically with subsequent place-
ment of PD stent. Patient later disclosed having a
remote episode of pancreatitis and prior surgical
pseudocyst drainage, which confirmed our clini-
cal suspicion of pancreatic fistula.
Most PPs resolve spontaneously and uneventful-
ly. 1,3 Rarely, PP may have communication with
PD, in which case may arise, a rare complication
of fistula formation to other viscera. 1,3 Pathogene-
sis of PP is believed to be due to disruption of the
main PD or peripheral ductules causing leakage
and activation of pancreatic enzymes, which fur-
ther explains the formation of the fistula. 1,3 Symp-
tomatic fistulae present as pain, fever, septicemia,
and compression of neighboring structures. 1,2
Endoscopic drainage via cystgastrostomy or
cystoduodenostomy is the preferred approach
followed by placement of PD stent to allow further
drainage and fistula healing. 3 Performed inde-
pendently, both drainages are effective, safe, and
well-coded and the expertise on these procedures
is widespread. 3 Surgical drainage is reserved for
recurrence or for endoscopic failures. 1,3
Figure 1
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