A case of perforated pancreatic pseudocyst complicated by acute myocardial infarction successfully treated by EUS-guided transgastric drainage.

CONTEXT Endoscopic ultrasound guided transmural drainage is a well accepted treatment modality for symptomatic pancreatic pseudocysts. Pseudocyst perforation is an indication for surgery. The safety and utility of endoscopic drainage in the setting of acute myocardial infarction is unknown. This report described a case of perforated pseudocyst in a patient with acute myocardial infarction successfully treated by endoscopic ultrasound guided drainage. CASE REPORT An 81-year-old man was admitted for acute myocardial infarction precipitated by anemia. Computer tomography showed a 17x11 cm pancreatic pseudocyst. Two days later he developed increased pain and computer tomography showed evidence of pseudocyst perforation. There was further intracystic bleeding that precipitated a second acute myocardial infarction. There was no peritonism presumably due to the fact that the pseudocyst wall had resealed temporarily. He was considered too high risk for surgery and hence underwent endoscopic ultrasound guided pseudocyst drainage. Endoscopic drainage was successful and his symptoms improved. Three weeks later, endoscopic retrograde pancreatography was performed to evaluate the pancreatic duct integrity; this showed a pancreatic duct fistula communicating with the pseudocyst cavity, and pancreatic duct stenting was performed. There was complete resolution of both the pseudocyst and pancreatic duct fistula. Follow-up computer tomography performed 3 months after removal of stents showed no pseudocyst recurrence. CONCLUSIONS In the setting of acute myocardial infarction and contained pseudocyst perforation, endoscopic ultrasound guided drainage may be performed successfully.