Severe Vascular and Ductal Complications of a Pancreatic Pseudocyst: A Case of Hemorrhage, Superior Mesenteric Vein (SMV) Compression, Duct Disconnection, and Portal Vein Thrombosis

Pancreatic pseudocysts (PPCs) are a common complication of chronic pancreatitis, particularly in alcohol-related disease. While many pseudocysts resolve spontaneously, enlarging or symptomatic collections may lead to hemorrhage, vascular compression, thrombosis, or disconnected pancreatic duct syndrome (DPDS), a condition increasingly recognized in patients with necrotizing pancreatitis. A 62-year-old man with chronic alcohol-related pancreatitis and recurrent PPCs presented with several weeks of severe epigastric pain radiating to the back. Computed tomography (CT) imaging revealed two enlarging pseudocysts (6.6 cm and 5.3 cm) in the uncinate process, with severe superior mesenteric vein (SMV) compression, fat stranding, new hemorrhage into a pseudocyst, upstream pancreatic duct dilation, and right portal vein branch thrombosis. Symptoms improved with supportive care, and outpatient endoscopic evaluation was pursued. Endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) demonstrated walled-off necrosis and active contrast extravasation in the pancreatic neck, confirming pancreatic duct disconnection. Due to the gastroduodenal artery encircling the collection, cyst-gastrostomy was deemed unsafe. Instead, a limited pancreatic sphincterotomy was performed, followed by placement of a straight pancreatic duct stent across the disconnection. The patient had subsequent resolution of his pseudocysts and continues to be followed as an outpatient. This case illustrates how PPCs in chronic pancreatitis can lead to multiple severe complications, emphasizing the need for early detection and prompt endoscopic management to prevent recurrent collections and reduce morbidity. It further highlights the potential progression from pseudocyst formation to DPDS, where timely recognition of ductal disruption is crucial for restoring ductal continuity, limiting recurrence, and avoiding additional complications.