Pseudocyst Formation Ultrasonographic

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A.

C.

GONZALEZ,1

E.

L.

in Acute Evaluation

BRADLEY,2

A total of 99 patients admitted with a diagnosis of acute pancreatitis were studied by abdominal A- and B-mode ultrasonography in an effort to detect pseudocyst formation. Positive ultrasonic scans were noted in 52 cases. In three patients with positive sonography, surgical exploration did not demonstrate pseudocysts, giving a false positive rate of 8.3%. Of the negative studies four were proven incorrect at surgery or autopsy, yielding a false negative rate of 8.5%. Approximately one-fifth with cystic lesions underwent spontaneous resolution. Three additional patients with pseudocysts had spontaneous cyst-enteric fistulization demonstrated by radiography. The sensitivity and accuracy of pancreatic ultrasound demonstrated by this study established ultrasonography as the procedure of choice in detecting pseudocyst formation in patients with acute

Pancreatic

pseudocysts

two

[1-3].

to

However,

from

operative

the entire views our large

attempted docyst

been

per

1 00,000

incidence

to

hospital and

been may

with

to determine

the

by using

acute

actual

pancreatitis.

incidence

abdominal

We

of acute

ultrasound

centage Abdominal

(92.9%) pain,

occurred

in 79

and

A definite (38.3%). There on admission

from

tion

reflect

210

cases,

and

tional

pseu-

Received 1 2

Am

December

Department Department

J Roentgenol

to 2,400

was

(normal

was

the

grade

noted

In

7. 1976

of

those

detected

instances

the

bowel

marked

were 84 Somogyi

40-200

units).

patients units

in

1 0 cases

The

pseudocyst of 33

52 (52.5%)

pseudocyst.

In

sonognaphy.

In 1 6 of the was

rupture,

47

no Excluding

49

cystic degeneration within netroperitoneal salmonella

in There

or bowel. in table

2.

evidence

was

of

identified

positive the three

resolution

sonographically documented Two of the cases that showed Of

mass with

in

one,

pancreatomegaly

of stomach

patients

in

in one.

had sonographic

spontaneous

recurred.

of

In

lordosis

aorta

are summarized

(47.4%)

not done.

examined.

lumbar

evidence

at and

of pancreatosolid tumors

adenopathy

displacement findings

found gastric

cases

abdominal

of 49

a mass (38.3%).

was

showed

exaggerated

ultrasonognaphic

sequently

33

(67.3%). In contrast, 99 patients studied

of ultrasonic

Of the 99 cases,

enteric

conven-

in only

lesion

netropenitoneal of the

radiographic

exploration

studies,

no

with

of pseudo-

the

in 23

two,

; there In 30

ultrasonic

examination

an aneurysm

without

evidence

was sonographic evidence pseudocyst in 18 instances,

emaciation

and

were

x-ray

displacement

pancreas

one,

where

the

99

with leuko1 1 ,000 to

[5].

positive

studies

these 23, there megaly without

by

ultrasounds, cases

of cyst-

of pseudocyst

was

in 10 of 49 patients (20.5%). spontaneous resolution subcystic

lesions,

malignancies abscess.

3 proved and

one

to

be

was

a

Discussion

creatic

99

; accepted after revision March 30. 1976. Emory University School of Medicine, Grady Memorial Emory University School of Medicine, Grady Memorial

1 27 : 31 5-31

was

in 38

radiography technique

pseudocyst

has

been

to demonstrate [2, 3, 6, 7].

considered the

Significant

presence

315

Hospital, 80 Butler Street SE., Hospital, Atlanta, Georgia 30303.

Atlanta,

Georgia

the

30303.

most

of a pan-

displacement

1 9, 1 975

of Radiology, of Surgery,

fever

1). Three cases had radiocyst- enteric communica-

elsewhere

false

in per-

alcoholics. complaint,

;

sonographic

was not (table of spontaneous

are reported

barium

small

the

ranging A high

suspected presenting Low

mass

cases with positive ultrasound was palpated in only 38 of the

have

scanning.

1. Of

female, years).

were 57 patients (57.5%) ; counts ranged from

there

Excluding

sensitive in table

40 40

patients (57.5%) were febrile, from 99’F to 1 03.2’F (average,

palpable

cyst; in 23 there graphic evidence

Methods

is summarized

and

(79.8%).

Fifty-seven ranging

cases cytosis

Contrast profile

male (average

of 99 cases

1 00.4’).

of these

in

Findings clinical

were years

Upper GI series was done on 74 patients (74.7%) was radiographic suspicion of a mass in 64 instances.

Over a 2 year period, 99 patients were evaluated. The case material was obtained from Grady Memorial Hospital in Atlanta. Sonography was performed in the ultrasonic laboratory of the radiology department of this institution. All patients had a clinical diagnosis of acute or exacerbated pancreatitis, supported by history, physical findings. and laboratory studies. Their clinical profile is outlined in table 1 . Each of these patients w referred for an evaluation of pancreatic morphology by ultrasound. A- and B-mode abdominal ultrasonognaphy was obtained with 2.25 MHz, 1 3 mm transducer using conventional, bistable oscilloscopic display (Picker Echoview VIII). All examinations were done with the patient supine; transverse and longitudinal sonic tomograms were obtained of the entire abdominal cavity at 2 cm intervals. The standard criteria for identification of cystic abdominal mass were used [4]. Including : (1) identificatiort of a cystic structure 2 cm or larger in or near the region of the pancreas ; (2) identification of the cyst in two or more coincident planes ; (3) confirmation of B mode cystic appearances by simultaneous A mode cystic pattern obtained at low and at high sensitivity instrumental settings; and (4) differentiation of the gallbladder, fluid-filled stomach, or other nonpancreatic cystic structures by anatomic position, changes with patient rotation, overnight restudy, and/or complimentary radiographic data.

The

JR.1

were known on the most common

common. temperatures

sonography, Subjects

59

1 4 to 81

ranged

derived

not

CLEMENTS,

22,000/mI (average, 1 3,400/mI). There with elevated amylase on admission

admissions

have

studies

occur

L.

studied,

from

also with

of the disease process. This study rein the ultrasonic investigation of a

of patients

formation

reported

statistics

or postmortem

spectrum experience

number

have

1 2 patients

J.

patients age

pancreatitis.

from

AND

Pancreatitis: of 99 Cases

of

GONZALEZ

316

TABLE Clinical

and

Patients

TABLE

Acute

Profile

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with

Evaluation

Positive Ultrasound N=52

Profile

Positive

Sex:

Known

or suspected

Abdominal

alcoholics.

.

.

.

pain on admission

Elevated

temperature

on

Palpable abdominal Definite Questionable

admission

28 24 43(14-81) 48 41

31 16 37(18-62) 44 38

25

32*

16 8

22 11

Negative .

. .

displacement

Nodisplacement Spontaneous

cyst-entenic

28

14

29 43

28 41

30

23

8

10

100.4;

range,

sound:

§ Gastric

474

or small

: average,

1 3,1 00

Somogyi bowel

478

;

Documented Pseudocyst Cystic

3

.

1 1 .000-20,700.

units;

range,

units 260-2,400.

;

range,

anatomic

Salmonella

invasive and

formations

by

may

like

which

cause

limits

of serial

this

and after

on

our

tion

false 8.5%.

3 52 Ultrasound

2 2 4

it

in which 1 6 cases positive

the

creatitis, since it was nearly 50% (see table

of to

does

.

present were

There

cases.) found

were

three

by false

the diagnosis was in which exploration

not confirmed was not done.

rate

false

was

therefore,

common

8.3%. that

The

complication

demonstrated 2).

in 49

of of

99

*

refused,

Surgery

three;

Another graphic

to follow-up.

interesting

and

demonstration

1 3.

significant

finding

of gradual,

and

follow-up

cysts. In three instances, through dissection into regression upon

nor

the

stances The three

size

radiographic

sono-

regression

This

of patients

spontaneous or

is the

spontaneous

with

sonographic in the clinical acute

pseudo-

spontaneous drainage took place the gastrointestinal tract. Neither drainage

location

of the

in this series of cystic radiograph was positive

graphic

report

pan-

specific

and

cases,

lost

Two subsequently recurred, one proved by surgery. One found at surgery and one at autopsy. § Both found at surgery. less than 5 cm. I! 10 at surgery, four at autopsy.

fonmaacute

29 14

.

false

appeared

cyst.

There

intraperitoneal in 67.3%

positives

were

to depend were

no

rupture. of our cases,

demonstrated.

inand

Thus,

contrast studies were shown to be at a considerable disadvantage to ultrasound. In those cases where pancneatomegaly or other disease process accounted for the radio-

negative

pseudocyst

.

47

management

filling

However, lend itself to

not

.

of these lesions in 10 of 49 cases (20%). observation deserves special consideration

patients

show

[1 2]

.

Total

to

it is an

selection

1 6 patients

99 cases.

It appears,

is a relatively

is possible

had one instance of pancreatitis of procedure. (Retrograde pan-

in 52 of

without evidence of pseudocyst of pseudocyst documented

t

studies.

procedure

we have this type

ultrasonography

rate was

GI

Total

ultra-

gastric

angiography,

is reported

in 1 0 of

angiography,

positive cases at surgery and

1 by upper

ultrasound: Negative

extrinsic

creatography was not used in any of the In the present series, cystic abnormalities

Thus

19

False negative cases: Pancreatic abscess Cyst

may be of assistance In R#{246}schand Bret’s

by using

pancreatography

pseudocyst

serial study, developing

1

Total

Negative

21 0-1 .680.

Though

yield

performance

Retrograde

of the

abscess

Cyst documented at autopsy Cyst-enteric rupture documented series

has been reported to occur [3] of cases. However, many

arteriography.

diagnostic

procedure

the

15 3

Total

series [1 1 ] the diagnosis was confirmed in 1 00% of cases (eight of eight). However, in Ranniger and Saldino’s study [1 0] only half of the operatively proved pseudocysts were the

1 Ot

at surgery:

displacement.

duodenal compression. Arteriography in establishing the diagnosis [8-11].

increase

serial

malignancie

Recovery Absence

demonstrated

by

Negative

range,

Somogyi

the stomach and small bowel in as many as 82% [7] to 86% other

documented

1 1.000-22,000.

ultrasound

average,

resolution

1 6* 3

ultrasonography

99-103.2.

: average,

t Positive ultrasound average. 1 3.700 ; range Positive

Ultrasound

not documented found at surgery)

com-

munication Average,

Spontaneous

Patients

mass:

Leukocytosis on admissiont Elevated amylase on admissions Upper GI series:

Marked

No.

Patients with Negative Ultrasound

Cystic configuration False positive (not

Male Female Age(range)

2

Ultrasonographic Evaluation of Patients with Clinical Pancreatitis

of

Pancreatitis

Patients

a

AL.

1

Laboratory

with

ET

or

previously tis

accounted

of a mass

effect,

descriptive

suggested for

test [1 3],

the

clinical

ultrasound of

the

pancreatitis and

proved

mass with

radiographic

a more

formation.

As

peripancreatimass

ab-

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ULTRASONOGRAPHY

IN

PANCREATIC

normality in most instances. However, in eight instances there was evident pancreatic enlargement by ultrasound which was not detected radiographically. Finally, the overall accuracy of ultrasound in the diagnosis of pancreatic disease has been considerably en-

7.

hanced with the with a video-scan

9.

used

introduction converter

in this and other

normal allows

pancreas. for In our

nostic

test

formation

studies

The

opinion

scanning

between ultrasound

presently

in acute

[1 6-1 8], is blind

gray-scale

differentiation

tissue.

of scanning in a gray [1 4, 1 5]. The bistable

available

for

most

in detecting of

normal is the

this

and

1 0.

organ

inflamed

definitive

detecting

scale unit

8.

1 1.

diag-

pseudocyst

1 2.

pancreatitis. 1 3. REFERENCES

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