Drainage of a Pancreatic Pseudocyst via a Spontaneous Cyst Duodenostomy

51-year-old woman presented with 5 days of Aacute-onset severe epigastric and right upperquadrant pain associated with nausea and vomiting. Laboratory test results showed obstructive jaundice and acute pancreatitis. An abdominal ultrasound showed multiple stones within the gallbladder and a dilated common bile duct (CBD). A computed tomography (CT) scan showed evidence of severe necrotizing pancreatitis and the patient was started on intravenous fluids and antibiotics. Three days later, as a result of progressive obstructive jaundice and possible cholangitis, an endoscopic retrograde cholangiopancreatography was performed that showed a distal CBD stricture. Complete ductal clearance of stones could not be achieved and a plastic stent was placed. Symptoms improved and she was discharged home for elective cholecystectomy. Ten weeks later she returned with fevers, chills, and severe abdominal pain. The gallbladder and biliary stent were in place and liver function test results were normal. A CT scan of the abdomen now showed a 15 12.5 cm pancreatic pseudocyst (Figure A). Endoscopic cyst-gastrostomy was attempted 1 day after the CT scan. An esophagogastroduodenoscopy showed a large opening within the duodenal bulb leading into the pseudocyst cavity (Figure B). Minimal fluid was seen within the pseudocyst cavity along with trace amounts of adherent debris along the walls (Figure B). Endoscopic ultrasound confirmed a partially drained cystic collection. She returned 11 weeks later for endoscopic retrograde cholangiopancreatography, stent removal, and clearing of the CBD stones. The cyst-duodenostomy appeared well healed without evidence of a residual cyst cavity (Figure C); this was confirmed on CT scan (Figure D).