Journal of the Royal Society of Medicine Volume 85 May 1992
295
Case reports
Pancreatic pseudocyst due to fractured pancreas
Case presented to Clinical Section, 8 November 1991
M J Hershman MS FRCS R Maxweli R D Rosin MS FRCS Department of Surgery, St Mary's Hospital, Praed Street, London W2 Keywords: trauma; pancreas; pseudocyst
Most cases of blunt pancreatic trauma occur with associated injuries and require immediate management. Delayed presentation of the severe injury of isolated pancreatic fracture with traumatic pseudocyst is rare. Case report A previously well 39-year-old man complained of constant epigastric pain and an enlarging epigastric swelling. Hi had lost 10 lb in the previous 8 weeks. His symptoms dated from an assault 10 weeks previously during which he iped d transient loss of consciousness, abdominal trauma, left 10th and 11th ribs and bruising to his right arm and face. He attended a casualty department 2 days after the assault and was discharged with no follow-up arraxd4Ie was a heavy smoker and prior to the assault was driing 7 pints of beer a day. On examination he was a thin emaciated man with an 18 x 12 cm smooth, firm, tender, non-pulsatile, ic mass. Investigations revealed a serum amylase0f 3X65 iu (normal < 300 iu), and a serum gamma GT of 56 -iU (normal t < 50 iu). An abdominal ultrasound demonstrated neck of pancreas with a large pancreatic pseud_ypt. Both proximal and distal pancreatic fragments were ihipwn to be abdminal v scan functional by an intravenously e (Figure 1). ERCP confirmed ductal discontin4lty, at the pancreatic neck.
Figure 1. Intravenously enhanced abdominal CT scan showing traumatic pancreatic pseudocyst with functioning (bright) distal pancreas
Correspondence to: Mr M J Hershman, 111 Middleton Road, London Fields, Hackney, London E8 4LN
Figure 2. The operation performed was Roux-en-Y distal pancreaticojejunostomy and posterior cystgastrostomy
Preoperatively he was treated with total parenteral nutrition and octreotide acetate. At laparotomy the radiological findings were confirmed. The proximal pancreatic duct was oversewn at the fracture site and the distal pancreas drained into the small bowel via a Roux-en-Y loop. The pancreatic pseudocyst was drained using a posterior cystgastrostomy (Figure 2). Postoperatively he made an uneventful recovery and remained well and asymptomatic 6 months later. Discussion Forty per cent of pancreatic iWuries are caused by blunt abdominal trauma, the rest are due to penetrating injury'. Almost 60% of patients with blunt trauma have associated retroperitoneal injuries2. Pancreatic injury is usually diagnosed at initial injury, by a combination of physical signs and positive diagnostic peritoneal lavage or sometimes at emergency laparotomy8. The serum amylase is only elevated in approximately 80% of patients with blunt pancreatic trauma4. Delayed diagnosis of severe pancreatic injury as in our patient -who presented with a traumatic pseudocyst is rare. The mortality of pancreatic injury is approximately 3% and relates to the presence of associated injuries, particularly concomitant bowel injury and to the severity of pancreatic injury. Pancreatic injury severity has been -graded on a scale of I-IV4. For minor pancreatic injury (grade I) the morbidity is 9% and for severe injury (grade IV) it is 50%. Local complications include haemorrhage, infection, fistula and pseudocyst formnation. A pseudocyst is a localized collection of pancreatic secretion lacking an epithelial lining but pirossesng a clearly defined wall made of fibrous tissue and adjacent viscera5. In adults, pancreatic pseudocysts are usually due to gallstones or alcohol rat-her than trauma6. However in children trauma is- the most common cause of pseudocyst7. Our patient therefore presented us with two surgical problems: management ofthe pancreatic injury and of the pseudocyst. To manage pancreatic injuries ,it is essential to have knowledge of ductal anatomy. We were able t6 determine this preoperatively by ERCP. Grades I and U pancreatic injuries cai iusually be treated with drainage and have a low iicidence of local pancreatic complications. Our patient had a grade M pancreatic injury. Many authors recommend that grade- m and IV pancreatic injuries are treated by pancreatectomy 3. However, when resection necessitates a 75% or greater pancreatectomy, as in this case, there is a high incidence bf complications including later endocrine insufficiency. In this instance, particularly with xnctioning
0141-0768/92/ 050295-02/$02.00/0 © 1992 The Royal Society of Medicine
296
Journal of the Royal Society of Medicine Volume 85 May 1992
distal pancreas, Roux-en-Y pancreaticojejunostomy had been recommended8, and was performed. The other surgical problem was the traumatic pseudocyst. Pseudocysts per se may have major complications, including haemorrhage, infection, rupture and compression of surrounding viscera6. Several techniques are available for treatment of pancreatic pseudocysts including percutaneous drainage, endoscopic drainage, surgical drainage and pancreatic resection6. Percutaneous drainage is very effective for treatment of traumatic pseudocysts in children, but is less so in adults7. In this case, with a known duct transection and a laparotomy already decided on, surgical drainage by posterior cystgastrostomy was performed. References 1 Richardson JD, Polk HC Jr, Flint LM. Traurn& Clinical care and pathophysiology. Chicago: Year Book Medical Publishers, 1987
2 Northrup WF, Simmons RL. Pancreatic trauma: a review. Surgery 1972;71:27-43 3 Smego DR, Richardson JD, Flint LM. Determinants of outcome in pancreatic trauma. J Trauma 1985;25:771 4 Bouwman DL, Weaver DW, Walt AJ. Serum amylase and its isoenzymes: a clarification of their implications in trauma. J Trauma 1984;24:573-8 5 Ranson JHC. The role of surgery in the management of acute pancreatitis. Ann Surg 1990;211:382-93. 6 D'Egidio A, Schein M. Pancreatic pseudocysts: a proposed classification and its management implications. Br J Surg 1991;78:981-4 7 Burnweit C, Wesson D, Stringer D, Filler R. Percutaneous drainage of traumatic pancreatitis pseudocysts in children. J Trauma 1990;30:1273-7 8 Jones RC, Shires GT. Pancreatic trauma. Arch Surg 1971; 102:424-30
(Accepted 15 October 1991)
Budd-Chiari syndrome in association with polycystic disease of the liver and kidneys
A Bhupalan MB ChB MRCP K Talbot BSc MBBS A Forbes MD MRCP M Owen MBBS FRCR D Samson MRCP FRCPath I M Murray-Lyon MD FRCP Charing Cross Hospital, Fulham Palace Road, London W6 8RF
Case presented to Clinical Section, 10 May 1991
01--1,-.ii- -ER.
Keywords: Budd-Chiari syndrome; polycystic disease
The first reported case of polycystic disease of the liver and kidneys associated with Budd-Chiari syndrome is described. Case report A 47-year-old woman with a 7 year history of asymptomatic polycystic disease of the liver and kidneys was referred to the department of gynaecology -because of ascites and a uterine mass. Investigations showed haemoglobin 10.1 g/dl (normal range 11.5-16.5), white cell count 5.6x 1O9 (normal range 4.0-11.Ox9 10), platelet count 289x 1O9 (normal range 150-400x 109). Serum vitamin B12, folate and ferritin were normal. The urea and electrolytes and liver function tests were normal with a plasma albumin of 44 g/l (normal range 35-50 g/l). The ascitic protein content was 58 gll, and cytology and microbiological investigations were negative. Computerized tomography of the pelvis confirmed a uterine mass with inconclusive fibroid-like features. Laparetomy confirmed the fibroid and ascites but no other pelvic abnormality. Following hysterectomy she was well for one month before ascites recurred. On examination a cystic liver was easily palpable below the umbilicus. Routine biochemistry remained normal but the EDTA clearance was 65 ml/min (predicted GFR 83 ml/min). The 24-h urinary protein excretion was normal (
295
Case reports
Pancreatic pseudocyst due to fractured pancreas
Case presented to Clinical Section, 8 November 1991
M J Hershman MS FRCS R Maxweli R D Rosin MS FRCS Department of Surgery, St Mary's Hospital, Praed Street, London W2 Keywords: trauma; pancreas; pseudocyst
Most cases of blunt pancreatic trauma occur with associated injuries and require immediate management. Delayed presentation of the severe injury of isolated pancreatic fracture with traumatic pseudocyst is rare. Case report A previously well 39-year-old man complained of constant epigastric pain and an enlarging epigastric swelling. Hi had lost 10 lb in the previous 8 weeks. His symptoms dated from an assault 10 weeks previously during which he iped d transient loss of consciousness, abdominal trauma, left 10th and 11th ribs and bruising to his right arm and face. He attended a casualty department 2 days after the assault and was discharged with no follow-up arraxd4Ie was a heavy smoker and prior to the assault was driing 7 pints of beer a day. On examination he was a thin emaciated man with an 18 x 12 cm smooth, firm, tender, non-pulsatile, ic mass. Investigations revealed a serum amylase0f 3X65 iu (normal < 300 iu), and a serum gamma GT of 56 -iU (normal t < 50 iu). An abdominal ultrasound demonstrated neck of pancreas with a large pancreatic pseud_ypt. Both proximal and distal pancreatic fragments were ihipwn to be abdminal v scan functional by an intravenously e (Figure 1). ERCP confirmed ductal discontin4lty, at the pancreatic neck.
Figure 1. Intravenously enhanced abdominal CT scan showing traumatic pancreatic pseudocyst with functioning (bright) distal pancreas
Correspondence to: Mr M J Hershman, 111 Middleton Road, London Fields, Hackney, London E8 4LN
Figure 2. The operation performed was Roux-en-Y distal pancreaticojejunostomy and posterior cystgastrostomy
Preoperatively he was treated with total parenteral nutrition and octreotide acetate. At laparotomy the radiological findings were confirmed. The proximal pancreatic duct was oversewn at the fracture site and the distal pancreas drained into the small bowel via a Roux-en-Y loop. The pancreatic pseudocyst was drained using a posterior cystgastrostomy (Figure 2). Postoperatively he made an uneventful recovery and remained well and asymptomatic 6 months later. Discussion Forty per cent of pancreatic iWuries are caused by blunt abdominal trauma, the rest are due to penetrating injury'. Almost 60% of patients with blunt trauma have associated retroperitoneal injuries2. Pancreatic injury is usually diagnosed at initial injury, by a combination of physical signs and positive diagnostic peritoneal lavage or sometimes at emergency laparotomy8. The serum amylase is only elevated in approximately 80% of patients with blunt pancreatic trauma4. Delayed diagnosis of severe pancreatic injury as in our patient -who presented with a traumatic pseudocyst is rare. The mortality of pancreatic injury is approximately 3% and relates to the presence of associated injuries, particularly concomitant bowel injury and to the severity of pancreatic injury. Pancreatic injury severity has been -graded on a scale of I-IV4. For minor pancreatic injury (grade I) the morbidity is 9% and for severe injury (grade IV) it is 50%. Local complications include haemorrhage, infection, fistula and pseudocyst formnation. A pseudocyst is a localized collection of pancreatic secretion lacking an epithelial lining but pirossesng a clearly defined wall made of fibrous tissue and adjacent viscera5. In adults, pancreatic pseudocysts are usually due to gallstones or alcohol rat-her than trauma6. However in children trauma is- the most common cause of pseudocyst7. Our patient therefore presented us with two surgical problems: management ofthe pancreatic injury and of the pseudocyst. To manage pancreatic injuries ,it is essential to have knowledge of ductal anatomy. We were able t6 determine this preoperatively by ERCP. Grades I and U pancreatic injuries cai iusually be treated with drainage and have a low iicidence of local pancreatic complications. Our patient had a grade M pancreatic injury. Many authors recommend that grade- m and IV pancreatic injuries are treated by pancreatectomy 3. However, when resection necessitates a 75% or greater pancreatectomy, as in this case, there is a high incidence bf complications including later endocrine insufficiency. In this instance, particularly with xnctioning
0141-0768/92/ 050295-02/$02.00/0 © 1992 The Royal Society of Medicine
296
Journal of the Royal Society of Medicine Volume 85 May 1992
distal pancreas, Roux-en-Y pancreaticojejunostomy had been recommended8, and was performed. The other surgical problem was the traumatic pseudocyst. Pseudocysts per se may have major complications, including haemorrhage, infection, rupture and compression of surrounding viscera6. Several techniques are available for treatment of pancreatic pseudocysts including percutaneous drainage, endoscopic drainage, surgical drainage and pancreatic resection6. Percutaneous drainage is very effective for treatment of traumatic pseudocysts in children, but is less so in adults7. In this case, with a known duct transection and a laparotomy already decided on, surgical drainage by posterior cystgastrostomy was performed. References 1 Richardson JD, Polk HC Jr, Flint LM. Traurn& Clinical care and pathophysiology. Chicago: Year Book Medical Publishers, 1987
2 Northrup WF, Simmons RL. Pancreatic trauma: a review. Surgery 1972;71:27-43 3 Smego DR, Richardson JD, Flint LM. Determinants of outcome in pancreatic trauma. J Trauma 1985;25:771 4 Bouwman DL, Weaver DW, Walt AJ. Serum amylase and its isoenzymes: a clarification of their implications in trauma. J Trauma 1984;24:573-8 5 Ranson JHC. The role of surgery in the management of acute pancreatitis. Ann Surg 1990;211:382-93. 6 D'Egidio A, Schein M. Pancreatic pseudocysts: a proposed classification and its management implications. Br J Surg 1991;78:981-4 7 Burnweit C, Wesson D, Stringer D, Filler R. Percutaneous drainage of traumatic pancreatitis pseudocysts in children. J Trauma 1990;30:1273-7 8 Jones RC, Shires GT. Pancreatic trauma. Arch Surg 1971; 102:424-30
(Accepted 15 October 1991)
Budd-Chiari syndrome in association with polycystic disease of the liver and kidneys
A Bhupalan MB ChB MRCP K Talbot BSc MBBS A Forbes MD MRCP M Owen MBBS FRCR D Samson MRCP FRCPath I M Murray-Lyon MD FRCP Charing Cross Hospital, Fulham Palace Road, London W6 8RF
Case presented to Clinical Section, 10 May 1991
01--1,-.ii- -ER.
Keywords: Budd-Chiari syndrome; polycystic disease
The first reported case of polycystic disease of the liver and kidneys associated with Budd-Chiari syndrome is described. Case report A 47-year-old woman with a 7 year history of asymptomatic polycystic disease of the liver and kidneys was referred to the department of gynaecology -because of ascites and a uterine mass. Investigations showed haemoglobin 10.1 g/dl (normal range 11.5-16.5), white cell count 5.6x 1O9 (normal range 4.0-11.Ox9 10), platelet count 289x 1O9 (normal range 150-400x 109). Serum vitamin B12, folate and ferritin were normal. The urea and electrolytes and liver function tests were normal with a plasma albumin of 44 g/l (normal range 35-50 g/l). The ascitic protein content was 58 gll, and cytology and microbiological investigations were negative. Computerized tomography of the pelvis confirmed a uterine mass with inconclusive fibroid-like features. Laparetomy confirmed the fibroid and ascites but no other pelvic abnormality. Following hysterectomy she was well for one month before ascites recurred. On examination a cystic liver was easily palpable below the umbilicus. Routine biochemistry remained normal but the EDTA clearance was 65 ml/min (predicted GFR 83 ml/min). The 24-h urinary protein excretion was normal (
