title: Pancreatic pseudocyst-inferior vena cava fistula causing caval stenosis, left renal vein thrombosis, subcutaneous fat necrosis, arthritis and dysfibrinogenemia.
abstract: OBJECTIVE
  We describe the case of a 38 year old man, with a story of alcohol abuse, who developed a very painful nodular subcutaneous fat necrosis, fever and polyarthritis, denying any abdominal symptoms due to a pancreatic pseudocyst-inferior vena cava fistula.
  
  
  METHODS
  The authors discuss the unusual and protracted course with intermittent hyperamylasemia and hyperlipasemia related to clinical manifestations such as subcutaneous fat necrosis, polyarthritis, pleural effusion and dysfibrinogenemia, and vascular complications as inferior vena cava stenosis and left renal vein thrombosis without abdominal symptomatology.
  
  
  RESULTS
  After ultrasonograms and CT Scans showing a 3-4 cm cyst at the pancreatic head with a solid bud protruding into the pseudocystic cavity, and an ERCP showing a communication between the pancreatic duct and the pseudocyst but failing in demonstrating the vascular fistula, the patient underwent a Roux-en-y pseudocyst-jejunostomy and suture of the caval communication leading to complete recovery with normalization of laboratory findings.
  
  
  CONCLUSIONS
  In our case, the locally sclerosing activity of the enzymes in the endothelium led to a communication between the inferior vena cava and the pseudocyst and to a complete thrombosis of the left renal vein and to a stenosis of the inferior vena cava itself The fluctuance of the symptomatology severity was probably due to an intermittent opening of the passage between pseudocyst and vena cava. Such a clinical case, to the author knowledge, has never been reported.
  
  
  CONCLUSIONS
  When in presence of very high levels of amylasemia and lipasemia in spite of the paucity of abdominal symptomatology, and the onset of unusual complications such as panniculitis, pleural effusion, arthritis and coagulative disorders, a pancreatic pseudocyst-inferior vena cava fistula should be kept in consideration during diagnosis.
authors.affiliation: Department of General Surgery, University of Sassari, Faculty of Medicine, Sassari, Italy. albporcu@hotmail.com
authors.forename: Alberto
authors.initials: A
authors.lastname: Porcu
authors.forename: Pier Luigi
authors.initials: PL
authors.lastname: Tilocca
authors.forename: Luca
authors.initials: L
authors.lastname: Pilo
authors.forename: Francesca
authors.initials: F
authors.lastname: Ruiu
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Dettori
mesh_terms: D000328:Adult; D000347:Afibrinogenemia / Q000209:etiology*; D000437:Alcoholism / Q000150:complications; D001168:Arthritis / Q000209:etiology*; D003251:Constriction, Pathologic / Q000209:etiology / Q000601:surgery; D005218:Fat Necrosis / Q000209:etiology*; D006801:Humans; D008297:Male; D010180:Pancreatectomy; D010185:Pancreatic Fistula / Q000175:diagnosis / Q000209:etiology* / Q000601:surgery; D010192:Pancreatic Pseudocyst / Q000150:complications* / Q000175:diagnosis / Q000601:surgery; D012082:Renal Veins / Q000473:pathology / Q000601:surgery; D012307:Risk Factors; D050151:Subcutaneous Fat / Q000473:pathology* / Q000601:surgery; D016896:Treatment Outcome; D016157:Vascular Fistula / Q000175:diagnosis / Q000209:etiology* / Q000601:surgery; D014656:Vascular Surgical Procedures / Q000379:methods; D014682:Vena Cava, Inferior / Q000473:pathology / Q000601:surgery; D020246:Venous Thrombosis / Q000209:etiology* / Q000601:surgery