Large pancreatic pseudocyst with mass effect

Case contributed by Craig Hacking

Presentation

Diagnosis of alcoholic pancreatitis a month ago but self discharged. Represents with epigastric pain.

Patient Data

Age: 40 years
Gender: Male

The entire pancreas is contained within a large complex multiloculated fluid collection with average density of 12 HU, which extends from the splenic hilum, across the lesser sac into the paracolic gutters bilaterally. Mild amount of inflammatory stranding surrounding the pseudocyst at the region of the porta hepatis and surrounding the spleen. No loss of enhancement of the pancreatic parenchyma to suggest necrosis.

The portal vein opacifies normally but is mildly compressed as it passes posterior to the large collection. No portal vein thrombus. The splenic vein is markedly compressed by the large collection and barely discernable. Collateral venous vessels are located at the splenic hilum and around the stomach. The superior mesenteric vein opacifies normally.

The gastric mucosa appears edematous along with submucosal edema of the ascending colon, which may suggest some venous congestion. No dilated loops of large or small bowel to suggest obstruction. No free intra-abdominal air.

The liver, gallbladder, spleen, adrenals and kidneys have a normal appearance. No splenomegaly. The hepatic contour appears smooth.

No bony abnormality. Mild dependent atelectasis at the lung bases, which are otherwise clear.

IMPRESSION

  • Interval development of a large complex pancreatic pseudocyst since the previous CT one month ago, with mild inflammatory stranding at the porta hepatis and adjacent to the spleen.
  • Marked compression of the splenic vein by the large pseudocyst with development of collateral venous flow at the splenic hilum and around the stomach. No portal venous thrombosis is evident.
  • Mild ascending colitis is likely reactive as it passes directly adjacent to the right side of the largest locule of the pseudocyst. No pneumoperitoneum.

Case Discussion

This case is an example of how large pseudocysts can have significant mass effect.

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