CT of fluid collections associated with pancreatitis

Pancreatic pseudocysts complicated by splenic parenchymal involvement: results of operative and percutaneous management

Pancreatic pseudocysts are a common finding in acute and chronic pancreatitis, but most are small and uncomplicated, and do not require treatment. Pseudocysts with splenic parenchymal involvement are uncommon but have the potential for massive hemorrhage. Data on the clinical presentation and optimal treatment of this unusual complication of pseudocysts are lacking. The purpose of this review was to identify the clinical features of pancreatic pseudocysts complicated by splenic parenchymal involvement and to determine the outcome with nonoperative and operative therapy.

METHODS

A retrospective review of the medical records of all patients with pancreatic pseudocysts from December 1984 to January 1999 revealed 238 patients, of whom 14 (6%) had splenic parenchymal involvement. These medical records were reviewed in detail and all pertinent radiographs were reviewed by the authors to confirm splenic parenchymal involvement by a pancreatic pseudocyst.

RESULTS

Initial treatment included observation (n = 2), percutaneous drainage (n = 8), and surgery (n = 4). Of the eight patients treated by percutaneous drainage, one died, three required repeated percutaneous drainage, and three required surgical intervention. None of the patients treated primarily by surgery required additional therapy for the pseudocyst. Overall, 11 patients had complications of the primary therapy, and 25% of patients treated by surgery had significant hemorrhage. Complications included infection (n = 5), pseudocyst persistence (n = 4), bleeding (n = 2), multisystem organ failure (n = 2), gastric outlet obstruction (n = 1), and splenic rupture (n = 2).

CONCLUSIONS

Pancreatic pseudocysts complicated by splenic parenchymal involvement may have life-threatening clinical presentations and respond poorly to percutaneous drainage. Distal pancreatectomy and splenectomy are effective, but the complication rate is high.

Pancreatic pseudocyst located in the liver: a case report and literature review

Pancreatic pseudocyst in the liver is a rare complication of acute or chronic pancreatitis. However, its frequency seems to be increasing with modem imaging procedures. The authors report a case of pancreatic pseudocyst involving the left lobe of the liver that occurred in a patient who never showed clinical evidence of pancreatitis or pancreatic injury. Complete screening led to the discovery of alcoholic chronic pancreatitis. The pseudocyst was treated successfully by radiologic drainage. The pancreatic pseudocyst location and therapeutic approaches are discussed. A literature review uncovered 26 cases of hepatic pancreatic pseudocysts. Clinical presentation, imaging characteristics, and treatment of these cases are analyzed.

Long term outcome of endoscopic drainage of pancreatic pseudocysts

OBJECTIVE

Nonoperative drainage either by the percutaneous or endoscopic route has become a viable alternative to surgical drainage of pancreatic pseudocysts. Endoscopic drainage has been reported in a few small series with encouraging short term results. The aim of this study was to determine the indications, suitability, and long term outcome of transmural endoscopic drainage procedures.

METHODS

All patients presenting over a 2-yr period to a tertiary referral hepatobiliary unit with pancreatic pseudocysts were studied. Endoscopic drainage was performed in patients with pseudocysts bulging into the stomach or duodenal lumen. Outcome measures were successful drainage of the pseudocyst, complications, and recurrence rates.

RESULTS

Of 66 patients presenting with pseudocysts, 34 were considered suitable for endoscopic drainage. Twenty-four (71%) were successfully drained. Failures were associated with thick walled pseudocysts (> 1 cm), location in the tail of the pancreas, and pseudocysts associated with acute necrotizing pancreatitis. There were three recurrences (7%), two of which were successfully redrained endoscopically. The long term success rate (median follow-up, 46 months) of the initial procedure was 62%.

CONCLUSION

Transmural endoscopic drainage is a safe procedure with minimal complications. It should be the procedure of choice for pseudocysts associated with chronic pancreatitis or trauma, with a wall thickness of < 1 cm and a visible bulge into the gastrointestinal lumen. Forty percent of pseudocysts fulfilled these criteria in our study.

Acute pancreatitis masquerading as testicular torsion

A 40-year-old man presented with fat necrosis of scrotum as the complication of acute pancreatitis. Excessive fluid accumulation in the pancreas and the extrapancreatic spaces, including around the spermatic cord, was seen on computed tomography. Surgical specimen showed typical fat necrosis of tunica vaginalis and the spermatic cord. After the surgery, pain of the testicle subsided completely, without recurrence. From the clinical presentation alone, it had been difficult to differentiate this patient's condition from torsion of the spermatic cord.

Causes of increasing width of right anterior extrarenal space seen in ultrasonographic examinations

The right anterior extrarenal space is composed of the perirenal fascia, the right anterior perirenal space, the right anterior pararenal space, and the liver capsule. To clarify the probable causes of an increasing width of the right anterior extrarenal space, the width was measured using ultrasonography for a period of 8 months. The right anterior extrarenal space was measured 3 cm from the superior renal pole and the smallest width obtained in several different scan planes was used. In 1,114 ultrasound examinations, 35 patients were found to have an increased width of the right anterior extrarenal space. Among the 35 cases, the common probable causes for such a condition were found in 27 cases. Eight patients had hyperchogenicity in the right pararenal space, a condition considered to be due to an acute inflammation, including acute pancreatitis, acute cecal diverticulitis, acute appendicitis, ischemic bowel, acute cholangitis, liver abscess, and penetrated duodenal ulcer. Chronic inflammations of an adjacent organ, a previous history of laparotomy, a malignancy with peritoneal metastases, and treatment with corticosteroid were considered the causes behind the condition in the 19 patients with normal echogenicity. For the remaining 8 patients, causes were not found during the follow-up period. This study indicates that life-threatening diseases, such as acute or chronic inflammatory diseases and malignancy of the abdomen, could be the cause of an increase in the width of this space.

Ultrasonography, computed tomography and percutaneous intervention in acute pancreatitis: a serial study

Fifty-seven patients (45 males, 12 females) with a clinical diagnosis of acute pancreatitis were serially evaluated by ultrasonography (US) and computed tomography (CT). Thirty patients had a single study, 18 had one follow-up study while 9 had two follow-up studies. The aetiology was gallstone disease in 26% of patients and a history of chronic alcohol abuse in only 16%. No cause could be identified in 47% of patients; 22% of US scans were unsatisfactory for the evaluation of pancreas whereas CT was uniformly satisfactory. Peripancreatic inflammation was detected in only 29% patients on US compared with 91% on CT. Pancreatic abscesses were detected in 8 patients on CT and gas was present in all of them. Fourteen patients underwent guided interventional procedures (US, 12; CT, 2). On follow up after 3 months, worsening of inflammation was detected in 11% patients on CT, which was not detected on US. It is concluded from this study that CT is far superior to US in the evaluation of acute pancreatitis, detection of peripancreatic inflammation and its extension into the retroperitoneal compartments and mesentery, and also for the evaluation of fluid collections, haemorrhage and abscesses. However, US provides easy guidance for percutaneous interventional procedures and can be used for follow-up scans.

Modern management of pancreatic pseudocysts

Pseudocysts may develop as a complication of acute pancreatitis, chronic pancreatitis or pancreatic trauma. As new methods of imaging provide fuller information on their incidence and natural history, important differences are emerging between the pseudocysts of acute and chronic pancreatitis. Traditional surgical approaches to the management of pseudocyst are now being challenged by endoscopic techniques and interventional radiology. In the light of these developments the options available are reviewed and strategies for the modern management of pancreatic pseudocysts are suggested.

Mesenteric panniculitis presenting as a multilocular cystic mesenteric mass: CT and MR evaluation

Mesenteric panniculitis is a non-neoplastic, inflammatory process affecting the adipose tissue of the mesentery in adults with slight male predilection. Typical computed tomography (CT) or magnetic resonance imaging (MRI) findings are of either diffuse mesenteric infiltration or nodular mesenteric masses. We encountered a case of mesenteric panniculitis in a 26-year-old woman with the left upper quadrant pain and fullness, in which CT and MRI disclosed a large, ill-defined, multilocular cystic mesenteric mass. After surgery, the diagnosis of mesenteric panniculitis was made. The cystic components were dilated lymphatics due to lymphatic and venous obstruction by the mesenteric panniculitis.

Agenesis and pseudo-agenesis of the dorsal pancreas

Agenesis of the dorsal pancreatic anlage is a very unusual congenital anomaly. The case reported appears to be accompanied by hypertrophy of the ventral gland. Atrophy of the pancreas following an episode of acute pancreatitis is also very unusual. When the atrophy spares the uncinate process, it may also resemble agenesis of the dorsal gland.

Case report: pancreatic mediastinal pseudocyst--an unusual cause of palpitations

We describe a case of pancreatic mediastinal pseudocyst which presented atypically with palpitations due to marked cardiac compression. Computed tomography (CT) showed a large abdominal pseudocyst extending through the diaphragm into the posterior mediastinum. Surgical drainage produced rapid symptomatic relief and the pseudocyst resolved completely within 2 months.

A rare case of splenic hematoma following chronic pancreatitis--the diagnostic and therapeutic procedures

We describe herein a clinical case in which a subcapsular splenic hematoma complicated chronic relapsing pancreatitis. A pathogenetic mechanism is postulated that explains the subacute insorgence of the liquid collection with the diffusion of proteolytic enzymes between the splenic capsule and parenchyma. Radical therapy, consisting of exeresis of the cystic formation, splenectomy and caudal pancreatectomy, is recommended for this extremely rare complication.

Pancreatic pseudocyst in the left hepatic lobe: a report of two cases

The ultrasound and computed tomographic imaging features in a rare pancreatic pseudocyst of the liver are described in two patients. The pseudocysts occurred in the left lobe in both cases, one after a traumatic injury and the other after alcoholic pancreatitis. The possible topographical sequences with which pancreatic secretions entered the left hepatic lobe to form a cyst are discussed.

Pseudoaneurysms and bleeding pseudocysts in chronic pancreatitis: radiological findings and contribution to diagnosis in 8 cases

Pseudoaneurysms and bleeding pseudocysts are rare but life-threatening complications of chronic pancreatitis. This report summarizes our experience in 8 cases collected from among 250 patients admitted for chronic pancreatitis. We describe the radiological findings of nine vascular lesions and especially emphasize the contribution of recent radiological imaging, ultrasound and computed tomography scanning in establishing the diagnosis of vascular complication. We also report a case of successful embolization of a splenic pseudoaneurysm that ruptured into the colon.

Subcutaneous soft tissue densities: a computed tomography indicator of severe pancreatitis

Twenty patients with known acute pancreatitis had 50 computed tomography studies. Those with severe pancreatitis showed streaky and fluffy soft tissue densities in the flanks and some in the gluteal regions. The appearance and disappearance of this finding correlates with the extravascular movement of fluid due to severe pancreatic inflammation.

Medial extent of the posterior renal fascia. An anatomic and computed tomography study

To study the medial extent of the posterior renal fascia and the perirenal space, the authors dissected two cadavers and reviewed 50 computed tomographic (CT) abdominal scans. The results demonstrated that the medial extent of the posterior renal fascia depends on the level in a vertical direction and its relationship to the kidney which varies at different levels. At the renal hilus, the fascia inserts posteromedially to the fascia of the quadratus lumborum along its lateral margin; more cranially, the line of insertion is more lateral, onto the diaphragmatic fascia; more caudally, the line of insertion is more medial, inserting onto the anterior surface of the quadratus lumborum. Therefore the posteromedial insertion of the posterior renal fascia extends medially, from the more laterally placed diaphragmatic fascia, to the lateral margin of the quadratus lumborum and then to the anterior surface of the quadratus lumborum, depending on the anatomic level. The clinical implication of these findings are discussed.

The spleen in inflammatory pancreatic disease

As the pancreas and the spleen lie in close proximity, splenic complications may occur in the course of acute or chronic pancreatitis in the form of isolated splenic vein thrombosis, intrasplenic pseudocysts, splenic rupture, infarction, and necroses as well as splenic hematoma and severe bleeding from eroded splenic vessels. Diagnosis is usually made under emergency conditions and is mainly based on ultrasound and computed tomography plus bolus injection and splenoportography. Additionally, ultrasound- or computed tomography-guided needle aspiration of fluid collection in the left upper quadrant may be helpful. Such conditions may be life threatening and, according to the increasing number of case reports, may be more frequent than is thought. They must be added to the list of other important extrapancreatitic complications such as shock and respiratory and renal failure. This review summarizes the present knowledge on splenic complications in acute and chronic pancreatitis for purposes of timely diagnosis and treatment and draws attention to the need for follow-up examinations of the spleen by imaging procedures in the course of acute and chronic pancreatitis.

Psoas muscle pancreatic pseudocyst: CT--US diagnosis and percutaneous drainage

We present 2 cases of psoas muscle pancreatic pseudocysts. In both cases there was no clinical or laboratory evidence of recent acute pancreatitis. The route of extension for the pseudocyst from the pancreas to the psoas was the perirenal space. In both cases the diagnosis was made on the basis of imaging studies and the pseudocysts resolved with percutaneous drainage only.

Acute pancreatitis

In order to recognize acute pancreatitis in the setting of the acute abdomen, the surgeon must be thoroughly familiar with the numerous etiologies of the disease. No specific test is available to diagnose acute pancreatitis. CT scanning is arguably the most useful single tool, but surgical judgment is critical. Most cases of acute pancreatitis resolve spontaneously without sequelae, but the spectrum of the disease also includes highly lethal forms associated with a variety of systemic complications. Operative intervention is indicated when other, more rapidly fatal, abdominal processes cannot be reliably excluded and when local complications develop.

Value of contrast-enhanced computerized tomography in the early diagnosis and prognosis of acute pancreatitis. A prospective study of 202 patients

Two hundred two patients admitted with the clinical suspicion of acute pancreatitis underwent computerized tomography scanning within 36 hours of admission. The diagnostic value of the computerized tomography findings was excellent, with a sensitivity of 92 percent and a specificity of 100 percent. One hundred seventy-six patients with acute pancreatitis defined according to the overall clinical course were included in the prognostic study. The pancreatitis was fatal in 21 patients, severe in 47 patients, and mild in 108 patients. The computerized tomography findings were classified into the following three groups on the basis of the extent of phlegmonous extrapancreatic spread: Group I, no phlegmonous extrapancreatic spread (100 patients, none died); Group II, phlegmonous extrapancreatic spread in one or two areas (28 patients, mortality rate 4 percent); and Group III, phlegmonous extrapancreatic spread in three or more areas (48 patients, mortality rate 42 percent) (p less than 0.0001). The following three scores from prognostic clinical and laboratory data were also obtained: Score 1, zero or one positive sign (82 patients, none died); Score 2, two to four positive signs (54 patients, mortality rate 13 percent); Score 3, five or more positive signs (40 patients, mortality rate 35 percent) (p less than 0.001). The combination of computerized tomography findings and prognostic signs had the best predictive value. Patients in Group III, Score 3 (24 patients) or Group III, Score 2 (19 patients) had mortality rates of 58 percent and 32 percent, respectively, and complications developed in all of the survivors. In addition, all except two acute pancreatitis patients in whom pancreatic abscess developed were found in Group III (p less than 0.0001). Furthermore, for Group III patients, the prediction of death associated with abscesses was enhanced by the number of prognostic signs. The mortality rate increased from 17 percent for Score 2 patients to 81 percent for Score 3 patients (p = 0.0078). As a result of this study, we recommend early computerized tomography for all Score 2 and Score 3 patients, since it allows prompt recognition of patients at high risk for systemic and local complications. Adequate therapy can then be directed to the group of patients to whom it is best suited. Serial computerized tomographies should be reserved for those patients presenting with phlegmonous extrapancreatic spread.

Controversies in the management of pancreatic pseudocysts

Review of the diagnosis and treatment of patients with pancreatic pseudocysts over the past 8 years has led us to three conclusions regarding controversial aspects of their treatment. We found that patients who present with chronic pseudocysts can be identified with the help of computerized axial tomography and promptly undergo successful internal drainage, whereas patients with acute peripancreatic fluid secondary to pancreatitis can be observed expectantly with a 43 percent frequency of spontaneous resolution. Patients with infected pancreatic pseudocysts can be safely drained internally. The most common cause of extrahepatic biliary obstruction in this group of patients with pancreatic pseudocysts was stricture due to pancreatitis and fibrosis, not extrinsic compression.

Pancreatic abscess: results of prolonged irrigation of the pancreatic bed after surgery

The mortality from pancreatic abscess may approach 70 per cent and the survivors often require repeated operations to debride the pancreas and to drain recurrent abscesses. We report the results of prolonged irrigation of the pancreatic bed after surgical débridement in 11 patients. Surgery was performed at an average of 17 days (range 8-25 days) after the onset of symptoms. The pancreatic slough was thoroughly debrided and 2-6 large drains were placed in the pancreatic bed. Irrigation with saline or Diaflex solution (2-6 l/day) was started after 2 days and continued for a mean of 25 days (range 5-54 days). There were three deaths (27.3 per cent) after surgery: one of these patients required reoperation and packing for massive postoperative haemorrhage and all three had some evidence of persisting sepsis at autopsy. Prolonged irrigation of the pancreatic bed after surgical débridement may reduce mortality and the need for repeated drainage procedures in patients with pancreatic abscess, but the detection and treatment of persisting sepsis remains the major problem.

Percutaneous drainage of pancreatic and peripancreatic fluid collections

Radiographically guided therapeutic percutaneous catheter drainage was used to manage 25 patients with 27 pancreatic and peripancreatic fluid collections. Nine of 11 (82%) noninfected and 11 of 16 (69%) infected collections were successfully managed with percutaneous drainage. Overall, eight complications and four deaths occurred in this group of patients. The morbidity and mortality in this series is somewhat higher than that previously reported in the radiologic literature. A discussion of the guidelines for percutaneous drainage is presented.

Early diagnosis of pancreatic infection by computed tomography-guided aspiration

We performed 92 computed tomography-guided percutaneous needle aspirations of pancreatic inflammatory masses in 60 patients suspected of harboring pancreatic infection. Thirty-six patients (60%) were found by Gram stain and culture to have a total of 41 separate episodes of pancreatic infection. Among 42 aspirates judged to be infected by computed tomography-guided aspiration, all but one were confirmed by surgery or indwelling catheter drainage. Among 50 aspirates judged to be sterile, no subsequent evidence of infection was found. All patients tolerated the procedure well and no complications were noted. As a result of this technique, we observed that pancreatic infection occurs earlier than has been previously appreciated (within 14 days of the onset of pancreatitis in 20 of the 36 patients) and that infection may recur during prolonged bouts of pancreatitis. We conclude that guided aspiration is a safe, accurate method for identifying infection of the pancreas at an early stage.

Perirenal fluid collection complicating chronic pancreatitis: CT demonstration

Extrapancreatic fluid collections are a well-known complication of pancreatitis and may occur in unusual locations. Involvement of the left perirenal space is uncommon and has not yet been documented by computed tomography. One surgically proven case is described and pertinent radiologic findings are described.

Quantitative tissue characterisation in pancreatic disease using magnetic resonance imaging

Twenty-nine patients, 27 of whom had either inflammatory disease of the pancreas or pancreatic tumour, were studied by magnetic resonance imaging (MRI) and computed tomography (CT). Six healthy volunteers were studied by MRI alone. The pancreatic T1 and T2 relaxation times were calculated using a multipoint iterative method with data from seven total saturation recovery and six spin echo sequences. Magnetic resonance imaging can demonstrate the normal pancreas and a variety of pathological processes greater than 1-2 cm in size, but with less spatial resolution than CT. The relaxation-time results indicated no significant discrimination between chronic pancreatitis and pancreatic tumour. A significant elevation in the relaxation times was observed, however, in those patients with calcific chronic pancreatitis compared with the non-calcific chronic pancreatitic group and normal controls, suggesting a different pathophysiology for the two subgroups of chronic pancreatitis. The active phase of acute pancreatitis was associated with significantly elevated relaxation times, which returned to normal levels during the resolved phase of the disease. Associated extrapancreatic fluid collections were characterised by their very long relaxation times. The problems associated with spatial resolution, respiratory motion and lack of quantitative tissue characterisation suggest that MRI of the pancreas, using present methods, is unlikely to contribute to the overall management of patients with exocrine pancreatic disease.

Pancreatitis presenting as pleural effusions: computed tomography demonstration of pleural space extension of pancreatitis exudate

Reported are two cases of acute pancreatitis that presented as large pleural effusions in which the route of communication of the pancreatic fossa with the chest was demonstrated on computed tomography. The bloody effusions were right-sided in one case and bilateral in the other. Pleuropulmonary complications of pancreatitis and possible mechanisms for pulmonary involvement are presented.

Computerized tomography in the evaluation of the late complications of acute pancreatitis

The role of computerized tomography in the diagnosis and treatment of late complications of acute pancreatitis was evaluated in 25 patients with acute pancreatitis. The clinical severity of the pancreatitis was assessed by Ranson's criteria. In each patient. the scan showed abnormalities of the pancreatic and at least one intraabdominal extrapancreatic extension of the disease. The scan precisely locates the intraabdominal extensions secondary to acute pancreatitis, and thus can guide surgical drainage, but it is less accurate in differentiating solid infiltration of fat planes from necrotic collections. However, in most of our patients, the association of general signs of sepsis with a collection shown on computerized tomographic scan indicated necrosis requiring surgical drainage.

The anatomical basis for retrorenal extensions of pancreatic effusions: the role of the renal fasciae

Retrorenal extension of pancreatic inflammatory processes are considered to involve invasion of the posterior pararenal space. Analysis of computed tomographic (CT) images demonstrates preservation of posterior pararenal fat in most patients, implicating some other mechanism. We have examined the anatomical basis for these retrorenal extensions in static and functional studies of 12 cadavers using CT imaging, dissection and histological techniques. We observed that the posterior renal fascia was thicker than the anterior, that it could be easily separated into two layers by manual dissection and injections of liquid latex, that the inner (anterior) layer of the posterior fascia was continuous with the anterior fascia and the outer layer continuous with the lateroconal fascia. The point at which the two layers of the posterior fascia separated laterally and the medial extent of the posterior fascia varied considerably in CT scans of 100 patients. These data are interpreted to mean that pancreatic effusions extend posterior to the kidney by separating the two layers of the posterior renal fascia.

Pancreatitis: an important cause of abdominal symptoms in patients on peritoneal dialysis

In an eight-month period, four patients in our peritoneal dialysis program developed acute pancreatitis, an incidence significantly higher than that in our hemodialysis program. Diagnosis was difficult since the symptoms of pancreatitis were similar to those of peritoneal dialysis-associated peritonitis. Further difficulties in diagnosis were due to unreliability of serum amylase levels and "routine" ultrasound examinations in suggesting the presence of pancreatitis. Computerized tomography performed in three patients showed enlarged, edematous pancreata with large extrapancreatic fluid collections in all cases. Two patients died, one directly due to complications of pancreatitis. One patient was changed to hemodialysis and showed clinical and radiologic resolution of his pancreatitis. One patient remains on peritoneal dialysis but has now had four attacks of acute pancreatitis. No patient had classic risk factors for development of pancreatitis. Review of patient histories showed no common historical factors except for renal failure itself, peritoneal dialysis, peritonitis, catheter surgery, and hypoproteinemia. It is possible that metabolic abnormalities related to absorption of glucose and buffer from dialysate or absorption of a toxic substance present in dialysate, bags, or tubing can cause pancreatitis in patients on peritoneal dialysis. We feel that a diagnosis of pancreatitis should be considered when peritoneal dialysis patients present with abdominal pain, particularly if peritoneal fluid cultures are negative or if patients with positive cultures do not have prompt resolution of symptoms with appropriate antibiotic therapy.

Right ureteral obstruction associated with pancreatitis

In a 5-year review of 207 patients with acute pancreatitis examined by computed tomography, 124 (60%) had findings consistent with active (acute or acute superimposed on chronic) pancreatitis. Six patients (3%), in addition to having evidence for pancreatitis, had associated mild to moderate right hydronephrosis and proximal hydroureter. These patients' findings are presented with a discussion of the renal manifestations of pancreatitis.

Pancreatic phlegmon. Clinical features and course

The clinical course of 19 patients with pancreatic phlegmon, as diagnosed by computed tomography (CT) and clinical criteria, was assessed retrospectively and compared to that of eight patients with pancreatic abscess diagnosed either at surgery or with percutaneous aspiration. Controls consisted of 55 patients with uncomplicated acute pancreatitis without CT scans and 11 patients with acute pancreatitis in whom CT scans were negative or only consistent with acute pancreatitis (no phlegmon). The age, sex, and presumed etiology of the pancreatitis were not significantly different in the four groups. Patients with phlegmon had a higher incidence of severe pancreatitis as defined by Ranson's criteria, presence of an abdominal mass, as well as a longer duration of fever, abdominal pain and leukocytosis than controls without CT scans. With the exception of a palpable abdominal mass and fever lasting over five days, the results were similar when comparing the phlegmon group and controls with CT scans, although the severity of the disease and prolonged abdominal pain tended to be increased in the former patients. There was no statistically significant difference in clinical or laboratory criteria between the phlegmon and abscess groups, although the latter group had longer hospital stays and periods with no oral intake (npo). Management of patients with phlegmon tended to include TPN, longer npo periods, antibiotics, and longer hospital stay than in controls without CT scans. Controls with CT scans were managed similarly to the phlegmon group because of prolonged amylase elevation and abdominal pain. Percutaneous aspiration was successful in differentiating abscess from phlegmon in five of six cases. Major complications were rare in the phlegmon group and spontaneous resolution was the rule. Pancreatic phlegmon is a distinct clinical/radiologic entity which may be very difficult to differentiate clinically from pancreatic abscess. Early percutaneous thin-needle aspiration of the inflammatory mass (under CT guidance) seems to be the diagnostic procedure of choice. Management is nonsurgical unless complications arise. The role of TPN and antibiotics is unknown, and controlled studies of these therapeutic approaches in pancreatic phlegmon are needed.

Echocardiographic features of a mediastinal pancreatic pseudocyst

Cross sectional echocardiography detected a mediastinal pancreatic pseudocyst which caused extracardiac compression in a 49 year old man. Computed tomography confirmed the presence of a cystic lesion lying behind the heart and extending from the pancreas to above the carina. Surgical decompression resulted in resolution of the clinical and echocardiographic findings.

Computed tomography and the prediction of pancreatic abscess in acute pancreatitis

Pancreatic abscess has become the most common cause of death from acute pancreatitis. Since computed tomography (CT) permits noninvasive imaging of the peripancreatic anatomy, the relationship of early CT findings to late pancreatic sepsis has been evaluated in 83 patients with acute pancreatitis. Pancreatic abscesses developed in 18 patients and were responsible for five of the six deaths in this study. Initial CT findings were graded: A = normal, in 12 patients; B = pancreatic enlargement alone, in 19; C = inflammation confined to pancreas and peripancreatic fat, in 17; D = one peripancreatic fluid collection, in 12; and E = two or more fluid collections, in 23. The incidence of pancreatic abscess in grades A and B was 0%; in grade C, 11.8%; in grade D, 16.7; and in grade E, 60.9%. The severity of pancreatitis was also graded by previously reported prognostic signs as "mild" (0-2 signs) in 56 patients, "moderate" (3-5 signs) in 22, and "severe" (greater than or equal to 6 signs) in five patients. The incidence of abscesses in mild disease was 12.5%; in moderate, 31.8%; and in severe, 80%. Fluid collections on CT resolved spontaneously in 19 of 35 (54.3%) patients. Abscess developed in two patients with no fluid collections on initial CT study. No abscess occurred in 31 patients with CT grades A or B, and in one of 22 patients (4.5%) with CT grade C or D and less than three positive prognostic signs. Among 30 patients with CT grade E or CT grade C or D and three or more positive prognostic signs, 17 (56.7%) developed abscesses. All deaths were in patients with five or more positive prognostic signs. Early imaging of the pancreas by CT identifies a group of patients with increased risk of pancreatic abscess. Identification of this group is improved further by use of early objective prognostic signs.

Demonstration of an internal pancreatic fistula by computed tomography

The computed tomographic demonstration of a mediastinal pseudocyst communicating with the pancreatic duct in a patient with severe acute pancreatitis is reported. An awareness of this communication was essential in planning the appropriate surgical management.

The syndromes of pancreatic pseudocysts and fluid collections

The clinical and radiologic spectrum of pseudocysts associated with alcohol-induced pancreatitis is wide and variable. Several illustrative cases which delineate the diversity of syndromes that occur with pseudocysts are presented. A classification is proposed to facilitate a more coherent approach to the concept of pseudocysts and is based on the clinical presentation. Thus, in acute pancreatitis duct disruption and enzyme activation may result in intrapancreatic or extrapancreatic fluid collections. In calcifying chronic pancreatitis duct obstruction may result in pseudocysts of the head, body, or tail of the pancreas, which can enlarge and penetrate into extrapancreatic sites. This subdivision will assist in elucidating the natural history of pseudocysts and pancreatic fluid collections. Furthermore, it may establish new guidelines for diagnosis and therapy.

Mediastinal pancreatic pseudocyst

Among previous cases of mediastinal pseudocyst requiring surgical decompression, all but one had been found at surgery to occupy a position both in the mediastinum and in the upper abdomen. In the present case, although preoperative ultrasound and CT scans suggested that the pseudocyst was straddling the diaphragm, an abdominal portion could not be found at surgery, and the pseudocyst was drained successfully through the diaphragm by a Roux-en-Y loop of jejunum. Because ultrasound and CT scan may not be able to determine the precise relationship of a mediastinal pseudocyst to the diaphragm and the availability of the lower portion of the pseudocyst for surgical decompression, an endoscopic retrograde cholangiopancreatography is strongly recommended as part of the preoperative evaluation.

Computed tomography of pararenal fluid collections in acute pancreatitis

Acute pancreatitis is a serious condition with severe and, sometimes, fatal complications. In recent years, both computed tomography (CT) and ultrasound have improved the diagnosis of certain complications, particularly pseudocysts, extrapancreatic exudates and abscesses. A frequent site for extrapancreatic exudates is the pararenal space. Reports in the CT literature have suggested that pararenal exudates are rare on the right but common on the left in acute pancreatitis. A series is presented here of nine patients with acute pancreatitis, seven of whom had right pararenal exudates demonstrated on CT examination. Patients with diffuse pancreatitis had bilateral pararenal exudates whilst those with inflammation confined either to the head and neck or to the tail of the pancreas had appropriate unilateral exudates. The detection and drainage of extrapancreatic exudates in acute pancreatitis may significantly influence morbidity.