Question

A 48-year-old Caucasian man presents with severe epigastric pain radiating to the back after a bout of drinking.

2 weeks later, a repeat ultrasound showed a round, thin-walled hypoechoic lesion near the pancreas tail measuring 4 cm in its largest diameter and with some calcifications in its walls. MRCP visualized a communication between this cavity and the pancreatic duct. Endoscopic ultrasound detected an area of high-speed flow close to the gastric wall.

What is the most appropriate next step in management?

1. Perform angio-CT scan
2. Perform angiography with coil embolization
3 Refer for a Puestow procedure
4. Refer for ERCP and transpancreatic drainage of the cyst
5 Refer for endoscopic ultrasound (EUS)-guided transgastric drainage
6 Observation only

Answer 1

2. Perform angiography with coil embolization

The most appropriate next step in management for a patient with a pancreatic pseudocyst and high-speed flow detected near the gastric wall is to perform angiography with coil embolization to address the potential vascular issue.

Step-by-step explanation:

The patient presents with symptoms and imaging findings suggestive of a pancreatic pseudocyst with communication to the pancreatic duct. The presence of high-speed flow close to the gastric wall, as detected by endoscopic ultrasound (EUS), raises the concern for an associated vascular complication such as pseudoaneurysm or venous bleeding. The presence of this vascular flow necessitates further evaluation and possible intervention to prevent hemorrhage.

Given these findings, the most appropriate next step in management would be to perform angiography with coil embolization (option 2). Angiography can confirm the presence of a vascular lesion and coil embolization can be performed to prevent bleeding. This intervention targets the potential vascular issue directly and should precede any other interventions such as drainage procedures or surgery for the pancreatic pseudocyst.