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.