Pancreatic pseudocyst is a common complication of acute and chronic pancreatitis. However, spleen involvement in pancreatitis is rare. We present a patient with a pancreatic tail pseudocyst with splenic extension and rupture. Due to initial stability, conservative management was decided. However, he developed tachycardia with severe abdominal pain associated with signs of peritoneal irritation, requiring an emergency laparotomy. A large pancreatic tail pseudocyst was identified in addition to a ruptured spleen. Splenectomy and double layer hand-sewn gastrocystic anastomosis were performed. The patient had a satisfactory recovery and was discharged on the 11th postoperative day. Conservative management is an option in stable patients but with a high rate of failure. Surgery remains the standard choice in these cases.
