Psoas muscle pancreatic pseudocyst: CT--US diagnosis and percutaneous drainage

Rare extension of pancreatic pseudocyst with Mycobacterium abscessus into the iliopsoas muscle

Pancreatic pseudocyst is a well-known complication of both acute and chronic pancreatitis. Although extension into other anatomical sites is common, extension into the retrofascial space causing an iliopsoas abscess is exceedingly rare. Although its low incidence creates a diagnostic challenge for clinicians, early diagnosis is essential to prevent significant complications and poor patient outcomes. We present a case of iliopsoas abscess with unusual culture fluid growth in the setting of acute on chronic pancreatitis secondary to extension of a pancreatic pseudocyst. We also offer a brief review of the literature and pathophysiology of the condition.

Pancreatic pseudocyst extending into psoas muscle mimicking acute complicated diverticulitis: A case report

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Pancreatic pseudocysts (PP) are known sequelae of acute and chronic pancreatitis.

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Pseudocyst extension into the psoas muscles have been rarely described.

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Pancreatic pseudocyst can also masquerade as complicated diverticulitis.

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This is a rare case of PP successfully managed with percutaneous drainage.

Introduction and importance

Pancreatic pseudocysts (PP) are known sequelae of pancreatitis. In this case, we present a patient with a pancreatic pseudocyst extending to the left psoas muscle, initially masquerading as acute complicated diverticulitis.

Case presentation

A 43-year-old male with previous episode of pancreatitis presented with a one-week history of abdominal pain. Physical examination revealed left lower quadrant tenderness. A computed tomography (CT) showed a large intraperitoneal fluid collection extending to the left psoas muscle with segmental inflammation of the descending colon. The patient was managed medically with empiric antibiotic therapy for concern of complicated diverticulitis. Ultrasound-guided percutaneous drainage was performed and fluid analysis showed lipase >20,000 U/L. The patient was discharged home with the drain. At one month follow up a repeat CT showed resolution of the left psoas fluid collection. The drain was removed and the patient remained asymptomatic at two month follow-up.

Clinical discussion

Pancreatic pseudocysts are well-known complications of pancreatitis. In this case, we describe extension of a pseudocyst to the left psoas muscle. We identified twelve previously reported patients diagnosed with PP involving the psoas muscles. Our case is unique as there is no previously published case in which a pseudocyst masqueraded as complicated diverticulitis. In analysis of the literature, most patients were managed with percutaneous drainage. Only 50% had documented complete resolution on follow up; of those 75% had undergone percutaneous drainage.

Conclusion

Pancreatic pseudocysts that extend to the psoas muscle can mimic acute complicated diverticulitis upon presentation. These may be effectively managed with percutaneous drainage.

Extension of pancreatic pseudocyst into psoas muscle in a setting of acute pancreatitis

Pancreatic pseudocysts are known to extend beyond the confines of the pancreatic bed due to the digestive nature of enzyme rich pancreatic fluid. Extension of a pseudocyst beyond the retroperitoneum, along the retrofascial plane within the psoas muscle is, however, unusual, with only a handful of cases described in the literature. We report a case of a 28-year-old man who presented with right lumbar pain and painful ipsilateral hip extension. Imaging findings revealed extension of the pseudocyst into psoas along with features of acute pancreatitis. The pseudocyst was drained percutaneously under image guidance, which led to resolution of symptoms.

Pancreatico-psoas fistula: a rare complication of acute pancreatitis

The authors present a case of post endoscopic retrograde cholangio-pancreatography acute pancreatitis complicated by a pancreatico-psoas fistula, as well as reviewing similar previously published cases. The patient had a fluctuating clinical course over 4 months, developing multiple life-threatening complications including portal vein thrombosis, gastrointestinal bleeding, aspiration pneumonia and acute kidney injury on a background of chronic kidney disease. The authors followed the long-held surgical principle of draining sepsis and avoiding surgical intervention. The fistula dried up with conservative management and time also allowed portal venous collateral formation with resolution of his ascites.

[Fistula between Wirsung and psoas muscle]

We describe a rare case of fistula between the Wirsung duct and the right psoas muscle. The initial clinical presentation was localised in the thigh and successful treatment was achieved by exclusive mini-invasive techniques.