Hemorrhage from a pancreatic pseudocyst eroding the stomach, diaphragm, and splenic artery: a case report on integrated surgical and nursing management.

Background: Pancreatic pseudocysts (PPCs), common sequelae of pancreatitis, can lead to life-threatening complications. Hemorrhage from a PPC eroding into adjacent structures is a critical emergency with high mortality. However, a case involving simultaneous erosion into the stomach, diaphragm, and splenic artery, causing massive dual-compartment hemorrhage (gastrointestinal and thoracic), is exceptionally rare and presents a profound challenge for diagnosis and management, necessitating urgent, coordinated multidisciplinary intervention. Case Description: We report the case of a 56-year-old male with a history of chronic alcohol abuse and recurrent pancreatitis who presented with hematemesis, abdominal pain, and hemorrhagic shock. An urgent contrast-enhanced computed tomography (CT) scan and subsequent angiography revealed a large, complex PPC in the pancreatic tail. The pseudocyst had eroded through the posterior gastric wall, the left hemidiaphragm, and a branch of the splenic artery, causing active extravasation. This complex erosion resulted in both massive upper gastrointestinal bleeding and a large left-sided hemothorax. The patient was managed with a staged, multidisciplinary approach. Immediate resuscitation was followed by emergency selective coil embolization of the bleeding arterial branch, which successfully achieved initial hemostasis. After stabilization, he underwent a definitive open surgical procedure on hospital day three, which included distal pancreatectomy, splenectomy, complete pseudocyst excision, and primary repair of both the gastric and diaphragmatic perforations. Integrated throughout his care, the case management nursing model (CMNM) was pivotal in coordinating communication, ensuring adherence to perioperative protocols, and facilitating patient education, particularly on alcohol cessation. Despite a postoperative course complicated by a managed pulmonary infection and transient ileus, the patient recovered well without a pancreatic fistula and was discharged on postoperative day (POD) 17. He remained asymptomatic at his 3-month follow-up. Conclusions: This case highlights the successful management of a catastrophic PPC complication through a strategic hybrid approach combining emergency endovascular embolization and definitive surgery. The integration of the CMNM proved invaluable for navigating the complex perioperative pathway, enhancing multidisciplinary collaboration, and ultimately contributing to a favorable outcome. This integrated model warrants further consideration in the management of complex surgical emergencies.