Initial CT examination
A 60-year-old male patient with a history of alcohol abuse and chronic pancreatitis was referred to the emergency department because of progressive and fluctuating pain in the left upper quadrant/flank combined with a fever, present for 3 weeks.
The initial CT (Fig. 1) showed a pancreatic tail pseudocyst extending into the visceral side of the splenic hilum. There was atrophy of the pancreas with multiple calcifications in the pancreas parenchyma, corresponding to the known chronic calcifying pancreatitis. The patient was hospitalised and treated with antibiotics. His symptoms regressed and his laboratory findings normalised. No further intervention was scheduled and the patient was discharged with a new antibiotic schedule. Two weeks later the patient returned with a relapse of the left upper quadrant pain combined with nausea and vomiting.
Repeat CT examination (Fig. 2) showed the intrasplenic extent of the pseudocyst in the pancreatic tail had regressed a bit, but was now complicated with a large subcapsular haematoma, with mass effect on the splenic parenchyma. Furthermore ascites in the perihepatic region and in the pelvis, and a small left sided pleural effusion were also noted.
Splenic complications of pancreatitis are rare, with an estimated frequency of 1-5% . These include vascular injury, intrasplenic pseudocyst, abcess formation, haemorrhage, splenic rupture and splenic infarction . The splenic involvement can be explained by the location of the pancreatic tail along the course of the splenic vein and artery, and its close connection to the splenic hilum. A pseudocyst in the pancreatic tail or an extrapancreatic fluid collection can extend along this course, into the splenic capsula and visceral side of the splenic parenchyma. These splenic pseudocysts can resolve spontaneously or they can be complicated with a subcapsular haematoma, an intrasplenic haemorrhage or rupture of the spleen [1-4]. The haemorrhage is caused by the erosion of the small intrasplenic vessels by the pancreatic enzymes dissecting along the splenic parenchyma . A small splenic haematoma in a stable patient may resolve spontaneously, larger haematomas or an instable patient require intervention such as surgical resection of the spleen or a percutaneous drainage of the haematoma .
The possibility of splenic involvement should be kept in mind in patients with a distal pancreatitis. Patients with an intrasplenic extent of a pseudocyst or intrasplenic haemorrhage require strict follow up of clinical parameters and should be monitored with serial CT scans. In case of progressive findings, intervention such as surgical resection or percutaneous drainage are indicated.
Our patient underwent a distal pancreatectomy and splenectomy. Histopathologic examination of the resected spleen and pancreatic tail confirmed the intrasplenic extent of the pseudocyst and the splenic subcapsular haematoma. Histopathological analysis of the intra-abdominal fluid showed neutrophilic inflammatory reaction.
 Fishman EK, Soyer P, Bliss DF, Bluemke DA, Devine N. (1995) Splenic involvement in pancreatitis: spectrum of CT findings. AJR Am J Roentgenol 1995 Mar;164(3):631-5. (PMID: 7863884)
 Malka D, Hammel P, Lévy P, Sauvanet A, Ruszniewski P, Belghiti J, Bernades P. (1998) Splenic complications in chronic pancreatitis: prevalence and risk factors in a medical-surgical series of 500 patients. Br J Surg 1998 Dec;85(12):1645-9. (PMID: 9876067)
 Trivedi H, Shuja A, Shah BB. (2015) Intrasplenic Pancreatic Pseudocyst: A Rare Complication of Acute Pancreatitis. ACG Case Rep J 2015 Jul 9;2(4):202-3. (PMID: 26203437)
 (4) Fung HY, Chiu HH, Li JH, Huang CC. (2009) Pancreatic tail pseudocyst associated with spontaneous resolution of intrasplenic pancreatic pseudocyst. Am J Surg 2009 May;197(5):e46-7. (PMID: 19217606)
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.