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

Unusual Sites of Necrotic Collections in Acute Necrotizing Pancreatitis: Association with Parenchymal Necrosis and Clinical Outcomes

BACKGROUND

The presence of necrotic collection in acute necrotizing pancreatitis (ANP) at intra-abdominal sites other than the retroperitoneum has not been systematically studied.

AIM

To investigate unusual sites of necrotic collections at computed tomography (CT) and to evaluate association with pancreatic necrosis and clinical outcomes.

METHODS

This retrospective study comprised of consecutive patients with ANP evaluated between January 2018 and March 2019. Based on CT findings, patients were divided into two groups: collections at unusual sites (small bowel mesentery, mesocolon, omentum, subcapsular collections along liver and spleen, pelvis, anterior abdominal wall, and inguinoscrotal regions) and collections at usual retroperitoneal locations (lesser sac, gastrosplenic location, anterior and posterior pararenal spaces, and paracolic gutters). The differences in CT findings and clinical outcomes (need for drainage, length of hospitalization, intensive care unit admission, surgery, and death) between the two groups were evaluated.

RESULTS

A total of 75 patients with ANP were evaluated. There were 25 (33.3%) patients with collections in unusual locations. These included mesentery (n = 17), splenic subcapsular location (n = 7), omentum (n = 6), hepatic subcapsular location (n = 4), anterior abdominal wall (n = 3), pelvis (n = 2), and inguinoscrotal location (n = 1). Compared to patients with collections at usual locations (n = 50), there were no differences in the CT findings except complete parenchymal necrosis (32% vs. 0%, P = .001). There were no statistically significant differences in the clinical outcomes between the two groups.

CONCLUSIONS

Mesenteric collections are frequent in ANP. The other non-retroperitoneal sites are infrequently involved. There is no association between unusual sites of collection and clinical outcomes.

Pancreatic abscess within hepato-gastric ligament: case report of an extremely rare disease

Background

Pancreatic pseudocyst is a very common benign cystic lesion of the pancreas. It develops in 5–15% of patients with peri-pancreatic fluid collection following acute pancreatitis. Collection usually occurs within the lesser sac of the omentum (near the pancreatic head and body region). But in 20–22% cases, that may be extra-pancreatic like in the mediastinum, pleura, in the peritoneal cavity including the pelvis. The pancreatic pseudocyst typically contains brownish fluid with necrotic tissue sludge which may get infected giving rise to infected pseudocyst or pancreatic abscess. The present case is an unusual condition of a young alcoholic subject who was finally diagnosed as a case of a pancreatic abscess within hepato-gastric ligament and was managed with operative intervention.

To the best of the author’s knowledge, it is the first-ever reported case of a pancreatic abscess within the hepato-gastric ligament in the world. Literature was reviewed to explore potential etiopathogenesis and therapeutic strategies of this extremely rare condition.

Case presentation

A 38 years old gentleman, chronic alcoholic, having a previous history of acute pancreatitis 3 months back, presented with fever (102 degrees Fahrenheit) and a huge [20 cm (horizontal) X 15 cm (vertical)] severely painful swelling in the epigastric region. The swelling was round-shaped, intra-abdominal, fixed to deeper tissue, tense-cystic, poorly trans-illuminant, non-pulsatile and irreducible. Routine blood tests showed leucocytosis (14,500/mm³) with neutrophilia and elevated plasma pancreatic amylase and lipase levels. USG and MDCT scan of the whole abdomen revealed a thick-walled echogenic cystic swelling of size 18 cm × 12 cm in the epigastric region. USG guided aspiration of the cyst revealed mixed purulent brownish fluid. The cyst fluid was negative for mucin stain and contained high amylase level with low CEA level, suggesting infected pancreatic pseudocyst.

An open drainage procedure was considered through an upper midline laparotomy. Aspiration of the pus mixed cyst fluid along with tissue debris was done. Through irrigation of the cyst was done with normal saline. The cyst wall was de-roofed leaving a small part adherent to the inferior surface of the left lobe of the liver. Later the cyst fluid culture showed significant growth of Escherichia coli. He was put on IV antibiotics. The patient was discharged in a stable condition after 5 days. The histopathological examination confirmed pancreatic abscess.

Six months after the operation, the patient is doing well, remaining asymptomatic and there is no sign of recurrence.

Conclusions

Due to extreme rarity, pancreatic abscess formation within hepato-gastric ligament may be a diagnostic dilemma and requires a high index of suspicion. Surgeons should be aware of this rare clinical entity for prompt management of potential morbidity.

Intrahepatic Pancreatic Pseudocyst Complicated by Pancreatitis: A Case Report

Pancreatic pseudocyst is a common complication of acute pancreatitis. Pseudocysts are commonly observed in the lesser sac and retroperitoneum; they are rarely seen in the liver. Herein, we report a case of intrahepatic pseudocyst, complicated by asymptomatic groove pancreatitis, that has successfully been treated with hepatic resection. A 70-year-old woman was referred to our hospital with severe upper abdominal pain. Abdominal computed tomography scan showed 11x10 cm sized cystic lesion in the left lateral section of the liver. Appearance of the pancreas was relatively normal. Endoscopic aspiration revealed a high level of amylase in the cystic fluid. After endoscopy, signs of peritonitis were observed; then, a left hemihepatectomy was performed. Pathologic examination revealed an intrahepatic pancreatic pseudocyst. The presence of intrahepatic cystic lesion in patients with suspected pancreatitis should raise the suspicion of intrahepatic pseudocyst. Intrahepatic pancreatic pseudocysts may be the only clinical manifestation even without an episode of acute pancreatitis.

Intrahepatic pancreatic pseudocyst: A review of the world literature

AIM

To investigate and summarize the literature regarding the diagnosis and management of intrahepatic pancreatic pseudocysts (IHPP).

METHODS

A literature search was performed using PubMed (MEDLINE) and Google Scholar databases, followed by a manual review of reference lists to ensure that no articles were missed. All articles, case reports, systematic reviews, letters to editors, and abstracts were analyzed and tabulated. Bivariate analyses were performed, with significance accepted at P < 0.05. Articles included were primarily in the English language, and articles in other languages were reviewed with native speakers or, if none available, were translated with electronic software when possible.

RESULTS

We found 41 published articles describing 54 cases since the 1970s, with a fairly steady rate of publication. Patients were predominantly male, with a mean age of 49 years. In 42% of published cases, the IHPP was the only reported pseudocyst, but 58% also had concurrent pseudocysts in other extrapancreatic locations. Average IHPP size was 9.5 cm and they occurred most commonly (48%) in the left hemiliver. Nearly every reported case was managed with an intervention, most with a single intervention, but some required up to three interventions. Percutaneous treatment with either simple aspiration or with an indwelling drain were the most common interventions, frequently performed along with stenting of the pancreatic duct. The size of the IHPP correlated significantly with both the duration of treatment (P = 0.006) and with the number of interventions required (P = 0.031). The duration of therapy also correlated with the initial white blood cell (WBC) count (P = 0.048).

CONCLUSION

Diagnosis of IHPP is difficult and often missed. Initial size and WBC are predictive of the treatment required. With appropriate intervention, most patients achieve resolution.

Fluid collections in and around the pancreas in acute pancreatitis

The advent of computed tomographic scan with its wide use in the evaluation of acute pancreatitis has opened up a new topic in pancreatology i.e. fluid collections. Fluid collections in and around the pancreas occur often in acute pancreatitis and were defined by the Atlanta Symposium on Acute Pancreatitis in 1992. Two decades since the Atlanta Conference additional experience has brought to light the inadequacy and poor understanding of the terms used by different specialists involved in the care of patients with acute pancreatitis when interpreting imaging modalities and the need for a uniformly used classification system. The deficiencies of the Atlanta definitions and advances in medicine have led to a proposed revision of the Atlanta classification promulgated by the Acute Pancreatitis Classification Working Group. The newly used terms "acute peripancreatic fluid collections," "pancreatic pseudocyst," "postnecrotic pancreatic/peripancreatic fluid collections," and "walled-off pancreatic necrosis" are to be clearly understood in the interpretation of imaging studies. The current treatment methods for fluid collections are diverse and depend on accurate interpretations of radiologic tests. Management options include conservative treatment, percutaneous catheter drainage, open and laparoscopic surgery, and endoscopic drainage. The choice of treatment depends on a correct diagnosis of the type of fluid collection. In this study we have attempted to clarify the management and clinical features of different types of fluid collections as they have been initially defined under the 1992 Atlanta Classification and revised by the Working Group's proposed categorization.

[Imaging of cystic liver diseases]

The high frequency of benign and asymptomatic liver cysts must not underevaluate the potential diagnostic difficulties of liver cystic diseases. Complicated liver cyst or cystic mass of various origin, such as developmental, neoplastic or inflammatory, are important to be recognized by the radiologist. The diagnostic approach is depending on the number of lesions and their dissemination. The presence of a wall, the internal structure of the lesion, particularly the MR signal and the proximity of the biliary tree are the main diagnostic criteria. Some less frequent but characteristic unusual features need to be memorized.

Multiple intrahepatic pseudocysts in acute pancreatitis

Liver pseudocysts are a very rare complication in acute pancreatitis with only a few cases previously described. The lack of experience and literature on this condition leads to difficulties in the differential diagnosis and management. We report herein a case of acute pancreatitis who developed multiple intrahepatic pseudocysts. After complete imaging evaluation, the diagnosis was still unclear and the patient was operated on. The presence of liver lesions in patients with acute pancreatitis should raise the possibility of intrahepatic pseudocysts.

[Pancreatic pseudocysts of the right hepatic lobe during acute biliary pancreatitis]

The occurrence of pancreatic pseudocysts of the right hepatic lobe during acute biliary pancreatitis is a rare event. We report the unusual case of a 69-year-old woman who was hospitalised for biliary pancreatitis. The patient suffered from right hypochondrial pain. A CT-scan performed at day 12 showed pancreatic pseudocysts in the right hepatic lobe. A favorable outcome was obtained after percutaneous drainage. Most hepatic pseudocysts are described in the left hepatic lobe after alcoholic pancreatitis. Different hypotheses have been suggested to explain the extension of pancreatic pseudocysts in the liver, due to proteolytic effect of pancreatic enzymes that reach the lesser sac and then the liver either directly through the liver capsule, or indirectly through the hepatic hilum vessels, or the hepatic ligament. We suggest another reason for hepatic invasion: pancreatic enzymes could also cause liver damage, through the para - renal anterior space, often infiltrated during acute pancreatitis, reaching right hepatic lobe through area nuda.

Cystic focal liver lesions in the adult: differential CT and MR imaging features

Cystic lesions of the liver in the adult can be classified as developmental, neoplastic, inflammatory, or miscellaneous. Although in some cases it is difficult to distinguish these entities with imaging criteria alone, certain cystic focal liver lesions have classic computed tomographic (CT) and magnetic resonance (MR) imaging features, which are important for the radiologist to understand and recognize. Lesions with such features include simple (bile duct) cyst, autosomal dominant polycystic liver disease, biliary hamartoma, Caroli disease, undifferentiated (embryonal) sarcoma, biliary cystadenoma and cystadenocarcinoma, cystic subtypes of primary liver neoplasms, cystic metastases, pyogenic and amebic abscesses, intrahepatic hydatid cyst, extrapancreatic pseudocyst, and intrahepatic hematoma and biloma. Specific CT and MR imaging findings that are important to recognize are the size of the lesion; the presence and thickness of a wall; the presence of septa, calcifications, or internal nodules; the enhancement pattern; the MR cholangiographic appearance; and the signal intensity spectrum. In addition, access to critical clinical information remains extremely important. The most important clinical parameters defined include age and gender, clinical history, and symptoms. An understanding of the classic CT and MR imaging appearances of cystic focal liver lesions will allow more definitive diagnosis and shorten the diagnostic work-up.

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.

Spontaneous rupture of a pancreatic pseudocyst into the portal vein

Spontaneous rupture of a pancreatic pseudocyst into the portal vein is described. This has been previously reported in only five cases. Diagnosis was made by computed tomography (CT) and was confirmed by CT-guided transhepatic portography.

Unusual cystic liver lesions: a pictorial essay

Cystic liver lesions are being increasingly detected by ultrasound (US), computed tomography (CT) and magnetic resonance imaging (MRI). These lesions produce a wide spectrum of radiological features. Unfortunately their appearance is not always specific and they may resemble and be mistaken for other lesions. Cystic lesions can be classified into congenital, inflammatory, neoplastic and miscellaneous groups. In this pictorial essay a number of unusual cystic lesions are illustrated with a brief analysis of morphological features of the individual lesion and a diagnostic approach for cystic liver lesions is suggested.