5 DISCUSSION
Pancreatic pseudocysts are organized loculated simple fluid collections
that lack an epithelial lining, contain a fibro-inflammatory lining made
up of fibrous and granulation tissue, and persist for more than 4 weeks
after the onset of pancreatitis. They are usually in the peripancreatic
location and less commonly in other locations.
Renal subcapsular extension of a pancreatic pseudocyst is extremely rare
and may mimic renal cortical cyst. Perirenal pseudocysts may compress,
displace, distort, or depress the kidney. These may result in “page
kidney”, which refers to renin-angiotensin-mediated hypertension
secondary to renal hypoperfusion following long-standing compression of
renal parenchyma by a subcapsular collection (12-14). Early management
of perirenal pseudocysts is, therefore, of high significance.
Pancreatico-renal fistula is a rare complication of pancreatitis. Its
pathogenesis typically involves the disruption of pancreatic duct
integrity due to inflammation, ductal obstruction, or tissue necrosis
(4). In the background of pancreatitis, the inflammation can lead to the
formation of abscesses or pseudocysts (8), which may erode into adjacent
structures with resultant fistula formation (3).
The clinical presentation depends on the extent of the fistula and
associated complications. Patients typically present with a
constellation of symptoms including abdominal pain, urinary symptoms,
electrolyte abnormalities, or recurrent urinary tract infections. These
may be associated with raised serum amylase and lipase levels. Diagnosis
may be confirmed through imaging studies such as CT, magnetic resonance
imaging (MRI), or endoscopic retrograde cholangiopancreatography (ERCP).
Managing pancreatic pseudocysts requires a multidisciplinary approach
tailored to the individual patient’s clinical presentation and
underlying etiology (9-11). Conservative measures such as fluid
resuscitation, pain control, and antibiotics may be initiated to
stabilize the patient and control symptoms. In cases of persistent
symptoms or complications such as infection or renal dysfunction, more
invasive interventions may be warranted. Endoscopic therapy, including
ERCP with stent placement or sphincterotomy, can facilitate drainage of
the pancreatic duct and promote closure of the fistulous tract. Surgical
intervention may be necessary in cases of failed endoscopic therapy,
extensive pancreatic necrosis, or recurrent complications. Surgical
options include fistula excision, pancreatic duct ligation, or partial
pancreatectomy, depending on the extent of pancreatic involvement and
the patient’s overall condition. In our case, surgical internal drainage
was performed on first admission. However, the patient was again
admitted with infected pseudocyst and an ultrasound-guided pigtail
drainage catheter was placed.
The prognosis of pancreatic pseudocysts depends on the severity of
pancreatic inflammation, the extent of adjacent tissue involvement, and
the timely initiation of appropriate treatment. With prompt diagnosis
and early intervention, most patients experience resolution of symptoms
and improvement in pancreatic and renal function. However, complications
such as recurrent pancreatitis, infection, or renal insufficiency may
occur, particularly in cases of delayed diagnosis or inadequate
treatment. Long-term follow-up is essential to monitor the recurrence of
symptoms and ensure optimal outcomes for patients with pancreatic
pseudocysts.