Case Report Mechanical Duodenal Perforation Due to Complications of Pancreatic Pseudocysts Jayan George 1,* , Chrysoula Fysaraki 1, Heather J. Harris 2, Krishnamurthy Ravi 1 and Timothy J. White 1 1 General Surgical Department, Chesterfield Royal Hospital Foundation Trust, Chesterfield Road, Chesterfield S44 5BL, UK; [email protected] (C.F.); [email protected] (K.R.); [email protected] (T.J.W.) 2 Radiology Department, Chesterfield Royal Hospital Foundation Trust, Chesterfield Road, Chesterfield S44 5BL, UK; [email protected] * Correspondence: [email protected]; Tel.: +44-1246-277271; Fax: +44-1246-516309 Received: 25 March 2020; Accepted: 15 April 2020; Published: 22 April 2020 Abstract: Pancreatic pseudocysts are a known complication of pancreatitis. There are a multitude of complications which have been described in relation to pancreatic pseudocysts. Perforation of a gastrointestinal hollow viscus is rare but has previously been reported. We report a case of a 72-year-old female with the development of three pancreatic pseudocysts four weeks post gallstone pancreatitis. The patient deteriorated and was found to have a duodenal perforation due to compression forces from the underlying pseudocysts. The patient required emergency surgical intervention and recovered fully following hospital admission. Keywords: pancreatic pseudocyst; gallstone pancreatitis; small bowel perforation 1. Introduction There are four types of pancreatic fluid collections as defined by the Atlanta guidance [1]. Pancreatic pseudocyst is one of these fluid collections. The pseudocysts are a maturing collection of pancreatic juice, encased by reactive granulation tissue, occurring in or around the pancreas because of pancreatitis (acute or chronic) or ductal leakage [2]. Pseudocysts are defined as pancreatic fluid collections, greater than four weeks old, surrounded by a defined non-epithelialised wall [3]. Several complications have been described relating to pancreatic pseudocysts [4]. We present a rare case of a large pancreatic pseudocyst leading to mechanical duodenal perforation. To our knowledge, this is the first case of this kind reported. 2. Case Presentation Section A 72-year-old female attended for a laparoscopic cholecystectomy on the background of severe gallstone pancreatitis four weeks previously. Examination prior to her operation revealed that she had an upper abdominal mass. The procedure was cancelled, and computed tomography (CT) was performed. This revealed a pseudocyst with three components—a large 16 12 cm thin-walled cyst × in relation to the head, body and proximal tail of the pancreas, a separate 6 cm cyst in the distal tail, and a 10 5 cm cyst in the area of the transverse mesocolon compressing the transverse colon × (Figures1 and2). Reports 2020, 3, 10; doi:10.3390/reports3020010 www.mdpi.com/journal/reports Reports 2020, 3, 10 2 of 6 Reports 2020, 3, x FOR PEER REVIEW 2 of 6 Figure 1. Axial post-contrast computed tomography (CT) scan of the upper abdomen showing a large pancreaticpancreatic pseudocystpseudocyst withwith thethe stomachstomach (arrows)(arrows) stretchedstretched anteriorlyanteriorly overover it.it. Figure 2.2 AxialAxial post-contrast post-contrast CT CT scan scan of of the upper abdo abdomenmen showing the inferior aspect of the cystcyst withwith bi-lobedbi-lobed appearanceappearance (arrows)(arrows) inin thethe pelvis.pelvis. Advice from thethe regionalregional hepatico–pancreatico–biliaryhepatico–pancreatico–biliary (HPB) unit waswas forfor conservativeconservative management until the walls of thethe pseudocystspseudocysts matured, whenwhen openopen drainagedrainage and cholecystectomycholecystectomy could bebe consideredconsidered ifif symptomssymptoms diddid notnot resolve.resolve. On day six her clinical condition deteriorated, she was pyrexial and haemodynamically unstable. The patient complained of increased abdominal pain and had a raised white cell count and a raised Reports 2020, 3, 10 3 of 6 On day six her clinical condition deteriorated, she was pyrexial and haemodynamically unstable. Reports 2020, 3, x FOR PEER REVIEW 3 of 6 The patientReports 2020 complained, 3, x FOR PEER of REVIEW increased abdominal pain and had a raised white cell count and3 of a raised6 arterial lactate level. An erect chest x-ray revealed free air under the right hemidiaphragm. Following arterial lactate level. An erect chest x-ray revealed free air under the right hemidiaphragm. Following initialarterial resuscitation lactate level. and An administration erect chest x-ray ofrevealed antibiotics, free air aunder CT wasthe right performed hemidiaphragm. revealing Following the known initial resuscitation and administration of antibiotics, a CT was performed revealing the known pseudocystinitial resuscitation with anterior and compression administration of the of stomach,antibiotics, free a CT fluid was in performed the abdomen revealing and considerable the known free pseudocyst with anterior compression of the stomach, free fluid in the abdomen and considerable pseudocyst with anterior compression of the stomach, free fluid in the abdomen and considerable intra-abdominalfree intra-abdominal air (Figures air (Figures3–5). 3, 4 and 5). free intra-abdominal air (Figures 3, 4 and 5). Figure 3. Axial CT scan of the abdomen showing free air anterior to the liver (white arrows) and free FigureFigure 3. Axial 3. Axial CT CT scan scan of of the the abdomen abdomen showingshowing free free air air an anteriorterior to tothe the liver liver (white (white arrows) arrows) and free and free fluid around the liver and spleen (black arrows). fluidfluid around around the the liver liver and and spleen spleen (black (black arrows). arrows). Figure 4. Axial CT scan of abdomen showing free air anterior to the liver (white arrows) and free fluid Figure 4. Axial CT scan of abdomen showing free air anterior to the liver (white arrows) and free fluid Figurearound 4. Axial the CTliver scan and ofspleen abdomen (black showingarrows). free air anterior to the liver (white arrows) and free fluid aroundaround the liverthe liver and and spleen spleen (black (black arrows). arrows). Reports 2020, 3, 10 4 of 6 Reports 2020, 3, x FOR PEER REVIEW 4 of 6 FigureFigure 5.5 Initially,Initially, Axial CT scan showing the stomachstomach containingcontaining a nasogastricnasogastric tube anterior to thethe cystcyst (large(large whitewhite arrow),arrow), freefree airair (small(small whitewhite arrows)arrows) andand inflammatoryinflammatory changeschanges inin thethe softsoft tissuestissues betweenbetween thethe stomachstomach/duodenum/duodenum andand thethe cystcyst (black(black arrow).arrow). AnAn emergencyemergency laparotomy laparotomy was was performed, performed, and aand large a 1.5large cm 1.5 split cm in thesplit first in partthe offirst the part duodenum of the withduodenum free bile with in thefree peritoneal bile in the cavity peritoneal was noted.cavity was In the noted. absence In the of aabsence duodenal of a ulcerduodenal and ischaemiculcer and change,ischaemic the change, cause of the this cause mechanical of this perforationmechanical couldperforation only be could attributed only be to excessiveattributed compressionto excessive ofcompression the duodenum of the from duodenum the underlying from the pseudocyst. underlying The pseudocyst. gallbladder The was gallbladder densely adherent was densely to the inflammatoryadherent to the phlegmon inflammatory and wasphlegmon left untouched. and was left Cystogastrostomy, untouched. Cystogastrostomy, pyloroplasty, omental pyloroplasty, patch andomental placement patch ofand nasojejunal placement feeding of nasojejunal tube were feeding performed. tube were A drain perf wasormed. placed A indrain Morrison’s was placed pouch. in TheMorrison’s patient waspouch. then The transferred patient to was critical then care transferre postoperatively,d to critical where care she remainedpostoperatively, for seventeen where days. she Sheremained was discharged for seventeen home days. on postoperative She was discharged day thirty. home Consent on postoperative was gained directlyday thirty. from Consent the patient. was gained directly from the patient. 3. Discussion 3. DiscussionPancreatic pseudocysts can cause a multitude of complications which have previously been reported—includingPancreatic pseudocysts gastric outletcan cause obstruction a multitude from of compression complications of which the stomach have previously or duodenum, been infection,reported—including pseudoaneurysm gastric formationoutlet obstruction and bleeding, from rupturecompression of the of cysts the eitherstomach intra-abdominally or duodenum, orinfection, into a viscus, pseudoaneurysm stress-related formation gastrointestinal and bleeding, ulcers rupture and fistulas of the [4 cysts,5]. Gastrointestinal either intra-abdominally perforation or relatedinto a toviscus, pseudocysts stress-related has previously gastrointestinal been described, ulcers butand itfistulas almost always[4,5]. Gastrointestinal followed a rupture perforation of a cyst intorelated the to lumen pseudocysts of the bowel has previously [6]. An example been ofdescribe this isd, an but unusual it almost case always of colonic followed perforation a rupture reported of a incyst a 71-year-oldinto the lumen male of with the abowel 10.5 cm[6]. pseudocyst An example which of this ruptured is an unusual causing case perforation of colonic at perforation the splenic flexurereported [7 ].in a 71-year-old male with a 10.5 cm pseudocyst which ruptured causing perforation at the