Hemorrhage from a pancreatic pseudocyst eroding the stomach, diaphragm, and splenic artery: a case report on integrated surgical and nursing management

Introduction

Pancreatic pseudocysts (PPCs) are fluid collections encapsulated by fibrous or granulation tissue, lacking an epithelial lining, that typically develop following pancreatic inflammation (acute or chronic pancreatitis) or pancreatic trauma. Their formation is associated with pancreatic enzyme activation, ductal disruption, and leakage of pancreatic fluid (1). The incidence of pseudocysts is approximately 7% in patients with acute pancreatitis and 30–40% in patients with chronic pancreatitis, with alcoholic pancreatitis being the most common etiology (59–78%) (2,3).

Although many resolve spontaneously, PPCs can lead to severe complications including infection, rupture, and hemorrhage (3). Hemorrhage, frequently caused by erosion into adjacent vessels like the splenic or gastroduodenal artery or associated pseudoaneurysms, constitutes a critical emergency with potential for massive gastrointestinal bleeding, hemothorax, or hemorrhagic shock, significantly increasing mortality (4). Cases involving simultaneous erosion into the stomach, diaphragm, and splenic artery with life-threatening hemorrhage are exceptionally rare, posing significant challenges for surgical teams requiring rapid diagnosis, stabilization, and coordinated interventions (5,6).

Effective critical care nursing supports surgical management, encompassing vigilant monitoring, resuscitation, and addressing complications like respiratory compromise (6). The case management nursing model (CMNM), a patient-centered approach with a dedicated Nurse Navigator, coordinates comprehensive care and has value in complex surgical settings (7,8).

We report a rare case of PPC eroding the posterior stomach wall, left hemidiaphragm, and splenic artery, causing upper gastrointestinal bleeding, hemothorax, and hemorrhagic shock. This report details the surgical management and the supportive role of CMNM in navigating the care pathway from emergency intervention through recovery. We present this article in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-194/rc).

Case presentation

All procedures performed in this study were in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Ethics Committee of the First Affiliated Hospital, Zhejiang University School of Medicine (approval No. 20250238). Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Patient information and initial assessment

A 56-year-old male presented to the emergency department with a 1-week history of left upper abdominal pain that acutely worsened 1 day prior and hematemesis (approximately 300 mL of bright red blood). Shortly before arrival, he experienced further hematemesis associated with dizziness, palpitations, and fatigue. His medical history was significant for heavy alcohol consumption (>20 years) and recurrent episodes of acute pancreatitis (2–3 per year, typically alcohol-induced). He had no other significant comorbidities, known allergies, or relevant family history. The patient’s clinical course is summarized in Table 1.

Clinical findings

On initial assessment, the patient presented with signs of hemorrhagic shock: blood pressure was 90/60 mmHg, heart rate was 90–110 bpm, and pallor was noted. Respiratory examination revealed decreased breath sounds on the left side. The abdomen was slightly distended and soft, with tenderness in the left upper quadrant but no rebound tenderness or guarding. Murphy’s sign and shifting dullness were negative. Bowel sounds were present.

Initial laboratory tests revealed anemia [hemoglobin (Hb) 90 g/L, dropping to 69 g/L in the intensive care unit (ICU)], elevated white blood cell (WBC) count (16.1×10⁹/L), C-reactive protein (CRP) (224.35 mg/L), and D-dimer [1,300 µg/L fibrinogen equivalent units (FEU)], with other values largely unremarkable.

Diagnostic assessment

An urgent contrast-enhanced computed tomography (CT) scan of the abdomen and chest was performed on the day of admission. Abdominal CT (Figure 1): revealed a large, complex, heterogeneous mass (approximately 8.5 cm × 6.0 cm) in the region of the pancreatic tail, extending superiorly towards the gastric fundus and perisplenic area. The mass appeared intimately related to the posterior gastric wall and the left hemidiaphragm. Arterial phase images showed heterogeneous enhancement with a focal area suggestive of active contrast extravasation or a pseudoaneurysm (Figure 1A). Tortuous, enlarged vessels were noted in the vicinity (Figure 1B). Chest CT (Figure 2): showed findings consistent with diaphragmatic involvement, demonstrating irregularity and thickening of the left hemidiaphragm adjacent to the pancreatic mass (Figure 2A). A large left-sided pleural effusion with heterogeneous density, suggestive of hemothorax, was present (Figure 2B). Associated compressive atelectasis of the left lower lobe with some contained air-fluid levels/cavities within the lung opacity and narrowing of adjacent bronchi were noted.

Figure 1 Preoperative contrast-enhanced abdominal CT imaging demonstrating the pancreatic pseudocyst (red arrow) and its relationship to adjacent structures. (A) The arterial phase shows heterogeneous enhancement and a focal area of nodular enhancement (suggestive of active bleeding). (B) Venous phase showing the large pseudocyst and associated dilated peripancreatic vessels. CT, computed tomography.

Figure 2 Preoperative contrast-enhanced chest CT imaging demonstrating diaphragmatic involvement and hemothorax. (A) The arrow indicates the left hemidiaphragm, which appears thickened and irregular. (B) The arrow indicates left-sided pleural effusion with heterogeneous density, consistent with hemothorax. CT, computed tomography.

Based on the clinical presentation and imaging findings, the diagnosis was a complex PPC eroding the posterior stomach wall, left hemidiaphragm, and splenic artery, complicated by splenic artery hemorrhage leading to upper gastrointestinal bleeding, hemothorax, and hemorrhagic shock.

Therapeutic intervention

Immediate resuscitation with intravenous fluids and blood products was initiated in the emergency ICU. An urgent multidisciplinary team (MDT) consultation involving general surgery, interventional radiology, gastroenterology, and critical care was convened.

Emergency embolization

On the day of admission, the patient underwent emergency digital subtraction angiography (DSA). This confirmed active extravasation from a branch of the splenic artery supplying the pseudocyst (Figure 3A). Selective coil embolization of the bleeding vessel was successfully performed, achieving immediate hemostasis (Figure 3B).

Figure 3 Digital subtraction angiography. (A) Arrow showing active extravasation from a splenic artery branch. (B) Arrow showing successful embolization with coils.

Definitive surgery

Following stabilization, on hospital day 3, the patient underwent exploratory laparotomy, distal pancreatectomy, splenectomy, excision of the PPC, primary repair of the gastric perforation, repair of the diaphragmatic defect, placement of a feeding jejunostomy tube, and insertion of a left-sided chest tube. Intraoperative findings confirmed a large (approx. 8.5 cm × 8 cm × 6 cm) pseudocyst arising from the pancreatic body/tail, with thick inflammatory walls densely adherent to and eroding into the posterior gastric wall (1.5 cm perforation) and left hemidiaphragm (3 cm perforation). Surgery duration was approximately 4 hours with an estimated blood loss of 800 mL.

Postoperative course and outcome, including nursing management coordinated by CMNM

Postoperative laboratory values on postoperative day (POD) 1 showed persistent anemia (Hb 65 g/L), elevated WBC (12.95×10⁹/L), and CRP (147.33 mg/L). The course was complicated by pulmonary infection (managed with antibiotics) and transient ileus on POD 9 (resolved conservatively with nasogastric decompression). No postoperative pancreatic fistula (POPF) occurred per International Study Group of Pancreatic Surgery (ISGPS) criteria (9), based on drain amylase and imaging. Enteral nutrition via jejunostomy was advanced, discontinuing parenteral nutrition on POD 14. Mobility progressed to independent ambulation.

From admission, the CMNM provided continuity by coordinating resuscitation monitoring, MDT communication, and integration of protocols [e.g., venous thromboembolism (VTE) prophylaxis, pain management, infection control]. It supported specialized care including chest tube and jejunostomy management, nutritional transitions, and wound care. Patient/family education on the condition, procedures, drain management, and alcohol cessation was facilitated. Discharge planning ensured a safe transition with diet, activity, and follow-up instructions.

The patient was discharged home on POD 17. At the 3-month follow-up visit, the patient reported being asymptomatic, recovering satisfactorily, and having no recurrence of symptoms.

Discussion

This case report details the management of a rare and life-threatening presentation of a complicated PPC, involving simultaneous erosion into the stomach, diaphragm, and splenic artery, resulting in massive dual-compartment hemorrhage (gastrointestinal and thoracic). The complexity stemmed not only from the severe initial presentation requiring immediate stabilization and intervention but also from the intricate surgical procedure and the potential for numerous severe postoperative complications in a patient with underlying chronic pancreatitis and alcoholism.

The initial strategy prioritized hemodynamic resuscitation and bleeding control via MDT-guided emergency angiography and selective coil embolization, serving as a bridge to definitive surgery (10,11). This aligns with current strategies for visceral artery aneurysms, highlighting interventional radiology’s role in pancreatic hemorrhage (12,13).

The definitive surgical intervention involved multi-organ resection and reconstruction, including distal pancreatectomy, splenectomy, pseudocyst excision, and repairs of the gastric and diaphragmatic perforations. These challenges such as dense adhesions and multi-site erosions, prolonged operative time, and increased blood loss. Associated risks included POPF [reported in 10–30% of similar pancreatic resections (9)], infection, and ileus (14,15). These were managed through standard preventive measures, including early enteral nutrition and antibiotic prophylaxis, illustrating the role of routine perioperative protocols in addressing morbidity for glandular surgery patients.

While technical interventions were essential, CMNM supported surgical success by providing continuity across care settings, acting as a communication hub, and ensuring protocol adherence (7). For instance, it coordinated VTE prophylaxis and comprehensive drain/tube management, potentially reducing risks of infection, thrombosis, and nutritional complications, while facilitating patient education on alcohol cessation, addressing a root cause of recurrent pancreatitis (16). This multifaceted role likely contributed to the smooth recovery and absence of major complications like delayed gastric emptying.

Existing literature supports nurse navigation in improving outcomes like satisfaction and reduced readmissions in complex cases (17,18). This case illustrates CMNM’s application in acute pancreatic surgery, suggesting potential for shortened stays (19). Compared to reports of PPC hemorrhage with isolated gastric or vascular erosion (2,4), our case of multi-organ involvement contributes to the literature by demonstrating the efficacy of hybrid approaches combining interventional radiology and open surgery in hemodynamically unstable patients.

This study has several limitations. Primarily, as a single case report, its findings cannot be generalized. A second key limitation is the short 3-month follow-up period, which precludes the assessment of significant late complications. The patient’s surgical procedure carries substantial future risks: distal pancreatectomy is associated with pancreatic exocrine insufficiency (20) and new-onset diabetes (21), while splenectomy creates a lifelong risk of overwhelming post-splenectomy infection (22), mandating patient education. Given these potential outcomes, a structured long-term follow-up, such as annual clinical and radiological assessments for at least five years, is essential for timely management.

Furthermore, the evaluation of the CMNM within this report has its own limitations. CMNM implementation can vary by institution, and this study lacks quantitative outcome metrics (e.g., cost savings or quality-of-life scores) to objectively measure its impact. Therefore, future studies, ideally controlled trials, are necessary to rigorously evaluate the CMNM’s effect on surgical outcomes in complex pancreatic resections compared to standard care.

Conclusions

This case demonstrates multidisciplinary management of a rare PPC complication causing massive hemorrhage via multi-organ erosion. Timely embolization and complex surgery (distal pancreatectomy, splenectomy) were pivotal, with CMNM enhancing outcomes through care coordination, education, and transitions. This model warrants further study in complex glandular surgeries to optimize patient care.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-194/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-194/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-194/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Ethics Committee of the First Affiliated Hospital, Zhejiang University School of Medicine (approval No. 20250238). Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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