Pancreatic pseudocyst-portal vein fistula: Unveiling a rare and critical clinical challenge

Pancreatic pseudocysts are common complications of acute and chronic pancreatitis, but fistulization into the portal vein is an exceptionally rare and life-threatening condition. We report the case of a 63-year-old woman with a history of severe pancreatitis complicated by portal vein thrombosis and a large pancreatic pseudocyst. Imaging studies, including contrast-enhanced computed tomography and magnetic resonance cholangiopancreatography, revealed a fistulous communication between the pseudocyst and the portal vein, associated with biliary compression and dilation. The patient initially improved under conservative management with antibiotics, analgesics, and anticoagulation. However, she later developed cholestatic jaundice requiring endoscopic drainage with placement of a metal stent, leading to favorable clinical and radiological evolution. Pancreatic pseudocyst–portal vein fistula remains a diagnostic and therapeutic challenge due to its rarity and nonspecific presentation. Imaging plays a key role, with MRCP being particularly useful for confirming the diagnosis. Management strategies vary depending on clinical presentation, ranging from conservative treatment to endoscopic or surgical intervention. This case highlights the importance of early recognition of this rare complication and supports a multidisciplinary approach, with minimally invasive management as a valid option in selected patients.