A 52-year-old man presents to his physician for follow-up 7 weeks after hospitalization for severe alcohol-associated acute pancreatitis. Since discharge, he has experienced persistent upper abdominal fullness, early satiety, and intermittent nausea. He reports no fever or recurrent severe pain. His medical history is significant for alcohol use disorder. He is not taking any medications. Temperature is 36.7°C (98.1°F), blood pressure is 126/78 mm Hg, pulse is 82/min, and respiratory rate is 14/min. Abdominal examination reveals mild epigastric fullness without rebound or guarding. Contrast-enhanced CT of the abdomen demonstrates an 8-cm encapsulated fluid collection adjacent to the pancreas.
Which of the following is the most likely diagnosis?
The correct answer is:
D) Pancreatic pseudocyst
This patient presents with a mature encapsulated pancreatic fluid collection several weeks after acute pancreatitis. The timing is one of the most important clues. Pancreatic pseudocysts typically develop at least 4 weeks after pancreatitis and consist of enzyme-rich fluid surrounded by a fibrous wall without a true epithelial lining. Patients commonly report persistent abdominal discomfort, nausea, early satiety, or symptoms related to compression of adjacent structures.
Most pseudocysts resolve spontaneously and can be observed if asymptomatic. However, intervention may be required when pseudocysts are large, symptomatic, infected, bleeding, or causing obstruction. Step 2 examinations frequently test recognition of the time course following pancreatitis, making the interval between the initial episode and development of symptoms a critical clue.
Answer choice A: Acute cholecystitis, is incorrect.
Acute cholecystitis typically presents with right upper quadrant pain, fever, leukocytosis, and a positive Murphy sign. It does not produce a mature fluid collection adjacent to the pancreas.
Answer choice B: Hepatocellular carcinoma, is incorrect.
Hepatocellular carcinoma develops within the liver and is usually associated with chronic liver disease or cirrhosis. Imaging would reveal a hepatic mass rather than a peripancreatic fluid collection.
Answer choice C: Pancreatic adenocarcinoma, is incorrect.
Pancreatic adenocarcinoma generally appears as a solid pancreatic mass and often presents with weight loss, jaundice, or new-onset diabetes. The temporal relationship to recent pancreatitis strongly favors a pseudocyst.
Answer choice E: Splenic infarction, is incorrect.
Splenic infarction typically causes acute left upper quadrant pain and is associated with embolic disease, hypercoagulable states, or hematologic disorders.
Key Learning Point
A pancreatic pseudocyst is a mature encapsulated fluid collection that develops weeks after acute pancreatitis and may cause abdominal pain, early satiety, or gastric compression.
