Massive polymicrobial suppurative pancreatic pseudocyst originating from cyst-enteric fistula involving the ileum.

t a a A man presented with 3 months of progressive diffuse abdominal pain, 40-pound weight loss, and fever. On evaluation e was afebrile, with cachexia and abdominal distention with diffuse enderness. White cell count was 10.7 K/UL. Hepatic transaminases nd lipase were normal, alkaline phosphatase was 121 U/L, and lbumin was 1.6 g/dL. Contrast-enhanced computed tomography emonstrated a large fluid collection (23 cm transverse 14 cm nterior-posterior 30 cm craniocaudal) filling the peritoneal cavity nd containing air, fluid, and debris with peritoneal enhancement Figures A and B). Ultrasound-guided aspiration was performed. Culure grew vancomycin-resistant Enterococcus faecium, Enterobacter cloaae, Klebsiella pneumoniae, and mixed aerobic flora. A repeat culture also rew Candida albicans. Echinococcus, amebiasis, and human immunodeciency virus serologies were negative. Amylase of fluid was greater han 24,000 U/L, suggesting the collection formed as a pancreatic seudocyst. The patient was treated with fluconazole, linezolid, and rtapenem. After clinical failure of percutaneous drainage, he underent exploratory laparotomy with resection of the suppurative panreatic pseudocyst and right hemicolectomy. The large thick-walled seudocyst contained more than 4 L of feculent fluid. There was vidence of ileal perforation resulting in cyst-enteric fistula. Pathology eport revealed no malignancy. He was discharged home on hospital ay 40 on fluconazole, levofloxacin, doxycycline, and metronidazole; he final diagnosis was polymicrobial suppurative pancreatic pseudoyst originating from cyst-enteric fistula involving the ileum. Pancreatic and peripancreatic fluid collections (APFCs) repesent a complex clinical dilemma. Collections may be sterile or nfected.1 APFCs can occur in up to 30%–50% of patients with acute pancreatitis, usually within 48 hours. More than 50% of APFCs resolve spontaneously within several weeks, whereas 30%–50% persist and form pseudocysts, similar to the clinical course in our patient.1 Many pseudocysts will resolve without intervention; however, expected course depends on many anatomic factors including cyst size.2 Reviews suggest that 73% of cysts that are more than 10 cm will require surgical drainage.3 Endoscopic therapies have replaced many indications for surgical intervention; however, surgery may still be required with pseudocysts refractory to endoscopic therapy.4 Because many pancreatic pseudocysts will self-resolve, imageguided aspiration on a routine basis is not recommended and may lead to secondary infection.1 Diagnosis of an infected pseudocyst may be challenging, and history, examination, presence of fever, and white blood cell count should be considered. Although imaging can define persistent peripancreatic fluid collections, aspiration of cyst contents is required for diagnosis of suppurative pseudocyst. The most common bacteria cultured include enteric microorganisms, including Escherichia coli, Bacteroides species, Enterobacter species, Klebsiella species, and Streptococcus faecalis.4 Antimicrobial treatment should be directed oward normal enteric flora until definitive microbiological data are vailable. There is no consensus regarding appropriate length of therpy; thus, treatment must be determined on an individual basis.