Spontaneous asymptomatic rupture of pseudocyst into stomach
The present case has been reported in BMJ. A 27-year-old woman presented with complaints of pain in the epigastric region radiating to back for 20 days. She was treated initially at local hospital and was diagnosed as acute pancreatitis as her amylase and lipase levels were >1000 U/mL. She was managed with analgesics and intravenous fluids and was discharged in 4 days.

She then presented to the emergency, with complaints of epigastric pain, awareness of lump in the epigastric region and non-passage of stool or flatus for past 3 days. She also gave history of fever and multiple episodes of bilious vomiting. Patient denied previous history of similar episodes in past and is non-alcoholic.

On abdominal examination, a lump of size 20×15 cm was palpable in the epigastric region extending into the umbilical region. On ultrasonogram abdomen, a cystic swelling was seen along with multiple gall stones in the gall bladder. Contrast-enhanced CT (CECT) abdomen was suggestive of a large cystic lesion with air-fluid levels occupying hepatoduodenal ligament lying anterior to the stomach and compressing anterior wall of stomach and duodenum.

A nasogastric tube was placed that drained around 800 mL bilious output on first day. Next morning, the nature of nasogastric output changed to purulent, and the lump disappeared. The following evening, the patient passed stool and flatus and underwent upper GI endoscopy the next day, which depicted a fistulous opening on the anterior wall of stomach with active pus discharge. At 6 months of follow-up, patient is asymptomatic and doing well.

Learning points
• Patients with asymptomatic, uncomplicated, stable or decreasing pseudocysts in size can be observed.

• Symptomatic, complicated and unstable patients with increasing pseudocyst size need an intervention in the form of percutaneous, endoscopic or surgical drainage.

• Conservative management seems appropriate in cases of silent, spontaneous, internal drainage, as in the present patient. However, one must remain cautious to detect complications early.

Read in detail here: http://casereports.bmj.com/content/2018/bcr-2018-226717.full