A Rare Case Report of Hepatic Subcapsular Pseudocyst of Pancreas

Abstract

A 33-year-old male, chronic alcoholic for 15 years, came to General Surgery OPD with pain upper abdomen radiating to the back for one and half months and upper abdominal fullness for three weeks. Pain was sudden in onset and severe in intensity, relieved on bending forward and aggravated on taking food. On chest X-ray patient had also developed generalized distension of abdomen with upper abdominal fullness of three weeks. The upper abdominal fullness had been increasing over time. Patient also had massive left sided pleural effusion [Table/ Fig-1] and developed respiratory distress for which a left sided Inter Costal Drainage (ICD) was put and about 800ml of blood tinged, amylase rich fluid was drained with relief of symptoms.Patient had similar episodes of pain abdomen on and off for last six years but the intensity was less severe and was relieved by medications. On per abdominal examination, abdomen was distended with tenderness over the epigastrium, left hypochondrium and umbilical regions. A 10x10cm tense, cystic and tender lump was palpable over the epigastrium with well-defined margins however, the upper border could not be felt. The lump had no movement with respiration and showed no side-to-side mobility. There was also free peritoneal fluid as evidenced by shifting dullness. Investigations revealed haemoglobin to be 11.2g%, total leucocyte count, differential leucocyte count, kidney function test, coagulation profile were within normal limits, serum amylase and lipase were raised at 700 and 863U/L respectively and pleural fluid amylase was also high at 223U/L. /Fig-2,3] showed a massive left sided pleural effusion with right mediastinal shift; a large 12x11x11cm sub-capsular collection with wall thickness of 6mm in the left lobe of liver causing scalloping of liver. The spleen also had a sub-capsular collection measuring 7x8x7cm; pancreas was heterodense around the body and tail and the Main Pancreatic Duct (MPD) was mildly dilated. Gallbladder and the extra-hepatic biliary system were normal. Contrast Enhanced Computed Tomography (CECT) abdomen [TablePatient did not have any haematemesis or melaena during the hospital stay but had a drop in haematocrit. Two units of packed red blood cells were transfused and the haemoglobin stabilized at 10g%.As the patient was stable except for severe pain, he was initially managed conservatively by keeping nil per oral, maintaining hydration by IV fluids and adequate analgesia, oxygen inhalation by facemask and SpO 2 monitoring. The pain and epigastric lump size was increasing in size; hence the subcapsular pseudocyst was drained percutaneous by placement of a 10 Fr malecot catheter under USG guidance [Table /Fig-4]. Approximately 500ml of cyst fluid was drained which was dark colored, with clots and high amylase level (6000IU/L). The USG repeated after seven days showed collapse of the cavity and resolution of the pseudocyst with no residual collection. During the two months follow-up, no peripancreatic or subcapsular collection was observed. DisCussion aBstRaCtA...

Pancreatic Pseudocysts at Unusual Sites: A Case Report

“…Pseudocyst as a complication of acute pancreatitis can occur at any site in the abdomen and even in the mediastinum, but the intrahepatic location of a pancreatic pseudocyst is a very uncommon event. In the literature, only 36 such cases have been described [2]. Most of them are either located in one lobe of the liver or are multiple, as in this case.…”

“…Computed tomography (CT) and high amylase levels obtained by the aspiration of the fluid play an important role in diagnosing this complication. In the literature, only 36 such cases have been described [2]. Spontaneous regression of intrahepatic pseudocysts may occur; therefore, no specific treatment is needed in the majority of cases [3].…”

An Infected Intrahepatic Pancreatic Pseudocyst and Calcified Pancreas: A Rare Complication of Chronic Pancreatitis

“…Around 20% of pseudocysts are detected in extra-pancreatic regions, including the mediastinum, liver, pelvis, pleura, and spleen, while about 80% are found in the body and head of the pancreas. Only 34 such occurrences of intrahepatic pseudocyst were documented in the literature until 2009 [ 4 , 5 ], making it a rare complication of pancreatitis. One in one hundred pancreatic pseudocyst instances extend into the spleen [ 6 ].…”

“…Draining is necessary when signs of nearby organ compaction are found. Action must be taken immediately if complications, including infection, rupture, or bleeding, occur [ 4 ]. Depending on the complexity of the pseudocyst, its communication with Wirsung's duct, and the presence of ductal damage, we may do endoscopic, percutaneous, or surgical drainage.…”

Pancreatic pseudocyst-portal vein fistula with refractory hepatic pseudocyst: Two cases treated with EUS cyst-gastrostomy and review of the literature

“…Pancreatic pseudocysts can present various complications, some more common such as infection, rupture, and gastrointestinal obstruction, to the slightly rarer. Hepatic pseudocysts are a recognized but rare phenomenon described within published case reports 7 8 9 10 11 12 . In one report of a patient presenting with a large liver cystic lesion in association with a pancreatic tail pseudocyst, the authors proposed several potential mechanisms for development of hepatic pseudocysts, including through direct invasion or possibly presence of heterotopic pancreatic tissue within the liver.…”