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Chronic pancreatitis with intrahepatic and intrasplenic pseudocysts

Case contributed by Levon Davtyan
Diagnosis certain

Presentation

History of pancreatitis. Re-presents with left hypochondrial pain.

Patient Data

Age: 65 years
Gender: Male

There is a hypoattenuating well-defined lesion in the tail of the pancreas, stretched to the left subphrenic space, with intrasplenic cyst with average density of 10HU and with a diameter of 10x8 cm.

There is also another similar lesion  (9x4 cm) that is stretched to the liver leading to 2 large intrahepatic lesions in segments II and III (11x6 cm and 9x4 cm).

There are also similar lesions abutting the stomach, in the lesser omentum and along the falciform ligament.

Atrophy of the pancreas with extensive calcifications - Chronic calcific pancreatitis

Low density regions in the spleen suggest the presence of splenic infarction.

There is also mild ascites and bilateral pleural effusion, more at left, with passive atelectasis. Minimal pericardial effusion. 

Already described lesions are pseudocysts resulting from pancreatitis.

Condition after insertion of percutaneous drainages intrahepatic and left subphrenic pseudocysts.

The sizes of the subphrenic pseudocysts have been considerably decreased.

The splenic pseudocysts have been non-significantly enlarged, the volume of left pleural effusion has been increased.

There are signs of inflammation of the drained pseudocysts.

After surgery of the intrasplenic pseudocyst, its sizes have been significantly decreased becoming 6x3 cm (had been 10x8cm).

There is no intrahepatic pseudocyst.

Case Discussion

The patient has a history of chronic calcific pancreatitis. Pancreatic enzymes digest fascial layers, spreading the inflammatory process to multiple anatomic departments.

Pancreatitis can cause serious complications including pseudocysts (encapsulated fluid collections usually after 4 weeks).

In the presence of severe pain and large pseudocysts not resolving with conservative management, percutaneous drainage can be used, as it is both diagnostic and therapeutic. 

The pseudocyst's fluid underwent successful percutaneous drainage and surgery, which showed clear fluid with high amylase, confirming these collections to be pancreatic pseudocysts. After being drained the size of the pseudocysts have decreased.

Intrasplenic pseudocysts

One of the main causes of splenic pseudocysts is locoregional inflammation. Pancreatic pseudocysts extend beneath the splenic capsule by tracking along the pancreatic tail to the splenic hilum.

Intrahepatic pseudocysts

A hepatic sub-capsular pseudocyst is a rare but known complication of pancreatitis and should be kept in mind when a sub-capsular collection is found in patients with a chronic or recent episode of acute pancreatitis. CT and a high level of amylase in the collection plays an important role in diagnosing this condition.

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