|Year : 1987 | Volume
| Issue : 2 | Page : 91-3
Mobile pseudocyst of pancreas--a diagnostic conundrum (a case report).
AS Upadhye, HM Nazareth, AM Hande, RD Bapat
A S Upadhye
|How to cite this article:|
Upadhye A S, Nazareth H M, Hande A M, Bapat R D. Mobile pseudocyst of pancreas--a diagnostic conundrum (a case report). J Postgrad Med 1987;33:91-3
|How to cite this URL:|
Upadhye A S, Nazareth H M, Hande A M, Bapat R D. Mobile pseudocyst of pancreas--a diagnostic conundrum (a case report). J Postgrad Med [serial online] 1987 [cited 2020 Jul 9 ];33:91-3
Available from: http://www.jpgmonline.com/text.asp?1987/33/2/91/5299
Pancreatic pseudocysts are encapsulated collections of necrotic tissue, old blood and secretions from the pancreas. The prefix pseudo is used to emphasize the fact that these collections frequently have no true capsule and that the cyst wall is made up of the adjacent viscera such as the stomach and colon. The cyst is usually round, smooth and tense, situated in the supra-umbilical region, being centrally placed and is almost always immobile. A mobile pseudocyst of the pancreas has, however, not been documented before. We are presenting here a case of mobile pseudocyst of pancreas which was under our care,
A 45 year old man presented with complaints of fullness after meals, anorexia, loss of weight and a lump in the upper half of the abdomen since 5 months. There was history of jaundice 1 year back. There was no history of nausea or vomiting, haematemesis or melena or change in the bowel habits. There was no history suggestive of an acute attack of pancreatitis and there was no fever or backache.
On examination, he was averagely built and nourished. There was no pallor, cyanosis or lymphadenopathy. There was mild icterus. There was fullness in the upper half of the abdomen without tenderness or guarding and a spherical intra-abdominal lump, 10 cm in diameter, well-circumscribed, firm and nontender. The lump was palpable in the right hypochondrium. It was mobile in all the directions, more in the transverse direction than vertical. There was no ascites. The liver and spleen were not palpable. Per rectal examination was normal. The other systems were normal. A differential diagnosis of gall bladder lump, mesenteric cyst, retroperitoneal mass, hydronephrosis or cyst of the pancreas was made in a clinical meeting.
On investigations, haemoglobin was 10.5 gm%, PCV 30%, a total count of 7600 per cmm; BUN 30 mg%, serum creatinine 1.2 mg%, serum amylase 112 IU/ml, total protein 6.7 gm%, albumin 3.7 gm%, and globulin 3.0 gm%. Serum bilirubin, amylase creatinine clearance ratio and serum electrolytes were within normal limits.
Plain X-ray of the abdomen was normal. A barium meal of the stomach and duodenum showed a widened loop of the duodenum [Fig. 1]. Ultrasonogram revealed a cystic area in the region of the duodenum and a differential diagnosis of mesenteric cyst or pancreatic pseudocyst was given by the sonologist.
With this information, a provisional diagnosis of pancreatic pseudocyst was made and the patient was explored. On the table, a pancreatic pseudocyst was found, 10 x 10 cm in size, with the duodenum stretching over it. The cyst was protruding through the mesocolon to the right of the middle colic artery. The walls of the cyst were thickened. A retrocolic Roux-en-y cystojejunostomy was performed. The patient recovered uneventfully. Histopathological report was consistent with the diagnosis of pancreatic pseudocyst. An ERCP done three months later showed a functioning cystojejunostomy.
A pancreatic pseudocyst can occur in various locations in the body and may also mimic pathology in other organs. The pancreatic secretions contain proteolytic enyzmes that facilitate the dissection of the mass of fluid along established tissue planes. The anterior pararenal space is filled first if the fluid leaks from the posterior part of the gland or from the tail. This may route along the right or left lumbar gutters, present as perirenal masses, and later track down in the groin or the scrotum. Fluid escaping posterolaterally may easily course along the splenic vessels via the hilum of the spleen into the splenic parenchyma.8,11
Fluid dissecting superiorly and posteriorly may pass between the crura of the diaphragm to enter the mediastinum,, and may present in the neck., Fluid in the lesser sac may easily protrude into the space between the stomach and left lobe of the liver by distending the hepatogastric ligament and later enter the liver.3 The most common presentation is a lump in the upper abdomen due to anterior perforation of the posterior layer of the parietal peritoneum leading to direct extension of the fluid into the lesser sac.2,5 As the pseudocyst matures and becomes encapsulated it may adhere to adjacent structures as a result of fibrosis.3 Hence, a pancreatic pseudocyst is usually well circumscribed and sessile. This case report documents a mobile pseudocyst of the pancreas, a previously undescribed entity which can lead to clinical confusion. It should be emphasized that a great majority of swellings in the upper abdomen which are mobile are other than due to the pancreas and are usually due to cysts in the omentum and mesentery or due to gall bladder, renal and intestinal pathology. A correlation of clinical findings and various investigative modalities including barium studies of the gastro-intestinal tract can lead one to an accurate diagnosis.
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