Unsuccessful splenic drainage

Clinical History

A splenic drainage was applied to a 45-year-old man presenting with left upper abdominal pain. Initial Computertomography and clinical history were likely for acute splenic hematoma. Though repeated CT showed significant reduction of the lesions size after removal of the drainage initial lesion size appeared again.

Imaging Findings

A 45-year-old man presented with acute left upper abdominal pain. He was collided by a car three months ago and received a blunt abdominal trauma. There was no history of alcohol abuse. Since then he suffered from severe pain in the left upper abdomen, developed slowly increasing fever (up to 38° C) and lost 10 kilograms of weight. CRP was increased (224 mg/l and leucozytosis 18.000 /ml), a lymphatic disease and echinococcus were excluded by blood samples. Ultrasound showed a large splenic liquid lesion. CT with a Lightspeed Ultra multislice Scanner, General Electric USA (collimation 2.5 mm, pitchquotient 13.5/1, 100 ml Accupaque iv, Flow 3.0 ml/s) was performed and demonstrated a large cystic lesion in the lateral spleen measuring 17 cm in diameter. Density was 36 Houndsfield units indicating old hematoma. In the medial site of the spleen there was a smaller hypodense area suspicious to be the origin of the fluid. Features like calcifications, ductal alterations or thickening of Gerota's fascia, inidcating pancreatitis were not visible. A 12 F Drainage (Pflugbeil, Germany) was applied to prevent surgery of the spleen. Fluid samples contained elevated levels of lipase and amylase, hematoma was excluded. CT control a week after the drain was applied proved a significant reduction of lesion’s size but secretion continued at a level of two litres per day. After removal of the drain the lesion had almost initial size again. A surgical drainage to the colon was performed because colon was closest to the pseudocyst.

Discussion

Drainage therapies of a variety of splenic lesions can be performed accurately and successfully if indication is made properly [1, 2, 3]. This case demonstrates a posttraumatic pancreaticosplenic fistula with a large intrasplenic pseudocyst [4].
Clinical history and initial presentation of the lesion mislead to expect posttraumatic splenic hematoma. Hints for pancreatitis or alcohol abuse were not given and not confirmed by CT. After having excluded lymphatic disease with spontaneous hematoma and echinoccoccus a drainage seemed to be indicated as a symptomatic therapy. Because of these facts an ERCP was not performed though in 62–80% "retrograde filling of the pseudocyst with contrast material proving the presence of a duct–pseudocyst communication" has beebn reported [5]. MRCP was not indicated due to a pacemaker. Ususally the main pancreatic duct can be identified within the pancreatic tail in more than 83% by MRI [6, 7]. Sensitivity of magnetic MRCP ranges from 70% and 92% if ERCP is the gold standard [5]. If a pancreatic duct injury has been detected supplying a pancreatic pseudocyst endoscopic transpapillary stenting of the pancreatic duct is a feasable therapeutic approach [7, 8]. Brennan PM et al. reported a complete resolution rate of 70% (21 of 30 patients) after a stenting therapy of 6 weeks. He noted no reocurrence within these patients for 45 months [8].
More common are endoscopic drainages of pseudocysts transpapillary or into the stomach or the duodenum by an transmural approach. Long-term success of these procedures is between 65% and 80%, though initial success is probably higher. Reoccurrence of pseudocysts occurs here in more than 20% [5].
When surgery becomes necessary there are laparoscopic and open techniques possible. Commonly cyst-gastrostomies or cyst-jejunostomies are constructed and are successfull [9, 10]. The initial surgical success of pancretic pseudocyst treatment has been described with 88% [5]. A cyst-colonostomy is a are technique but seemed most feasible in our patient.

Differential Diagnosis List

Final Diagnosis

Posttraumatic pancreatic duct fistula with communicating intrasplenic pseudocyst.

URL:	https://www.eurorad.org/case/4132
DOI:	10.1594/EURORAD/CASE.4132
ISSN:	1563-4086