PANCREATIC PSEUDOCYST EXTENDING INTO PSOAS MUSCLE MIMICKING ACUTE COMPLICATED DIVERTICULITIS
Nikhil R Shah MD, Sergio Mazzola Poli de Figueiredo MD, Joshua Person MD
Presenter: Nikhil Shah, MD, University of Texas Medical Branch – Galveston
Introduction/Objective: Pancreatic pseudocysts are known sequelae of pancreatitis. They are most commonly located in the lesser sac and extension into the psoas muscles have been rarely described. In this case, we present a patient with a pancreatic pseudocyst extending to the left psoas, initially masquerading as acute complicated diverticulitis.
Case Presentation: A 43-year-old male with a previous episode of acute alcoholic pancreatitis 2 years prior, presented to our institution with a one-week history of abdominal pain. Physical examination revealed left lower quadrant tenderness, while laboratory results showed leukocytosis, hyperglycemia, acute kidney injury and elevated lipase. A computed tomography (CT) showed a large intraperitoneal fluid collection (largest diameter 12.1cm) on the left hemiabdomen communicating with another fluid collection (largest diameter 11.4cm) on the left psoas muscle with segmental inflammation of the descending colon (Figure 1). The patient was managed medically with empiric antibiotic therapy for concern of complicated diverticulitis. Ultrasound-guided percutaneous drainage was performed with placement of a pigtail catheter. Biochemical analysis of the aspirated fluid was significant for amylase >2,400 U/L and lipase >20,000 U/L, confirming the presence of a pancreatic pseudocyst extending into the left psoas muscle. The patient continued to be managed medically and was discharged home with the drain in place. At one month follow up a repeat CT showed residual 2cm fluid collection at pancreatic tail with resolution of the left psoas fluid collection (Figure 2). The intra-abdominal drain was then removed and the patient remained asymptomatic at two month follow-up.
Discussion: Pancreatic pseudocysts are well-known complications of acute and chronic pancreatitis. In the presented case, we describe extension of a pseudocyst to the left psoas muscle. After searching the Pubmed database, we identified a total of twelve published patients diagnosed with pancreatic pseudocysts involving the psoas muscles. Our patient’s presentation was particularly unique as his initial complaint was localized left lower quadrant abdominal pain associated with an intra-abdominal fluid collection and inflammation of descending colon. There has been no previously published case in which a pseudocyst masqueraded as complicated diverticulitis. In analysis of the literature, most patients (6) were managed with percutaneous drainage. Four were managed surgically, one underwent endoscopic drainage and one patient managed conservatively. 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. After appropriate diagnostic workup, these may be effectively managed with percutaneous drainage.
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