Saudi Journal of Gastroenterology
Home About us Instructions Submission Subscribe Advertise Contact Login    Print this page  Email this page Small font sizeDefault font sizeIncrease font size 
Users Online: 1308 


 
CASE REPORT Table of Contents   
Year : 1996  |  Volume : 2  |  Issue : 3  |  Page : 160-163
Traumatic pancreatic pseudocyst


Department of Surgery, Armed Forces Hospital, Riyadh, Saudi Arabia

Click here for correspondence address and email

Date of Submission04-Dec-1995
Date of Acceptance14-May-1996
 

How to cite this article:
El Musharaf HA, Al Auriefi MA. Traumatic pancreatic pseudocyst. Saudi J Gastroenterol 1996;2:160-3

How to cite this URL:
El Musharaf HA, Al Auriefi MA. Traumatic pancreatic pseudocyst. Saudi J Gastroenterol [serial online] 1996 [cited 2019 Aug 22];2:160-3. Available from: http://www.saudijgastro.com/text.asp?1996/2/3/160/34023


Trauma to the pancreas constitutes 2% of all abdominal injuries. One-third of pancreatic injuries are due to blunt injury and the incidence may increase with the implementation of compulsory seat belt laws. The high mortality rate reported (20-40%) are due to the fact that considerable force is needed to damage the pancreas and this often affects other organs, mainly liver, mesentery or thorax. Complications including pancreatic abscess, fistulae, hemorrhage or pseudocyst, develop in one-third of those who survive [1],[2],[3],[4],[5] .

Pancreatic pseudocyst is a localized collection of pancreatic secretions lacking an epithelial lining as a result of pancreatic inflammation or ductal disruption. Trauma is an etiological factor in 3-8% of adult cases, but it is responsible for almost all pediatric pancreatic pseudocysts [6],[7] .

We are reporting a case of posttraumatic pancreatic pseudocyst managed successfully by percutaneous catheter drainage, and looking at the different aspects of this condition.


   Case Report Top


A 50-year-old Saudi male presented to us, five hours after being crushed between two cars, with upper abdominal pain. He was hemodynamically stable and clinical examination revealed tenderness in the epigastrium and sluggish bowel sounds. Hematological and biochemical investigations were normal apart from high serum amylase level of 585 U/L (0-120 U/L). Chest X-ray, plain abdomen X-ray and computed tomography of the abdomen were normal. He was admitted as a case of traumatic pancreatitis for observation.

The patient did well initially, but two weeks later he developed intolerance to oral intake, abdominal distension and vomiting. Clinically his abdomen was distended mainly at the epigastrium. Serum amylase was 232 U/L and a plain X-ray abdomen showed a large homogenous opacity in the mid-abdomen extending to the left side.

Pancreatic pseudocyst was suspected and this was confirmed by ultrasonography [Figure - 1] and computed tomograph [Figure - 2]. A duct-pseudocyst communication could not be demonstrated ultrasonographically, despite its presence on endoscopic retrograde cholangiopancreatography (ERCP) [Figure - 3].

Percutaneous drainage under CT scan guidance using 12F gauge pig tail catheter performed draining initially 2,480 mls of brownish fluid rich in amylase and on subsequent microbiological studies was sterile [Figure - 3].

Sandostatin as adjuvant treatment in a dose of 50 ugbid was started. Catheter was left in situ for 10 days and as the drainage was minimum for two consecutive days, an ultrasonography was repeated and demonstrated a small (<2 cm) cyst at the region of the body of the pancreas. Subsequently drainage was removed. CT scan a week later demonstrated no change in the cyst size [Figure - 4]. Complete resolution of the cyst was demonstrated on CT scan two months after discharge.


   Discussion Top


The retroperitoneal location of the pancreas makes pancreatic trauma a diagnostic dilemma. The physical findings may be absent or minimal, serum amylase is nonspecific, and peritoneal lavage is of no help. Even in the presence of associated visceral or vascular damage, which necessitates laparotomy, the presence of retroperitoneal hematoma will not allow accurate assessment of the pancreas. Furthermore a lacerated pancreatic duct may be concealed within an intact capsule [2],[4] .

Computed tomography can miss 20-40% of these injuries [1],[2] . Ultrasonography is less effective in evaluation of acute pancreatic injuries because of the gas interference. However, Gewth et al were able to demonstrate fracture through the body of the pancreas using conventional ultrasonography [3] .

Ultrasonography, although not effective in the acute phase, is an excellent tool for diagnosis of pancreatic pseudocyst, which is an early complication of traumatic pancreatitis, median time of presentation is 20 days, range 8-360 days post trauma [1] .

ERCP is 100% sensitive and specific in diagnosis of pancreatic ductal disruption [1],[2] . The ERCP in our case demonstrated the injury to be in the body and this is the classical site of pancreatic ductal injury, due to its relation to the vertebral column [5] .

According to D'Egidio A. and Schein M. classification of our case is type I pancreatic pseudocyst in which the pancreatic duct system is normal, despite duct-pseudocyst communication, and this type can be managed successfully with percutaneous drainage if indicated [8] . The indications for drainage in our case were gastric outlet obstruction as evident by vomiting, food intolerance and epigastric fullness, and the cyst diameter was 21cm x 10 cm on ultrasonography (more than the classical 6 cm diameter). Other indications for drainage are infection, rupture, colon obstruction and common bile duct obstruction [6],[7] .

The thickness of the wall of the cyst can be measured using ultrasound or CT scan, and cysts more than 1 cm in thickness will not resolve spontaneously as well as cysts present more than six weeks, or if there is pancreatic duct abnormality other than duct-pseudocyst communication [6] . Simple aspiration of pseudocyst is associated with recurrence rate of 70%, but percutaneous catheter drainage under ultrasonography or CT guidance is associated with success rate of 90% [6] .

Sandostatin "somatostatin analogue" has been effective as an adjuvant to catheter drainage as it decreases the basal and stimulated pancreatic secretion [9] .

Catheter can be removed when there is no more drainage and after the cyst resolution. In our case, in two conservative days, the drainage was minimum and an ultrasonography, prior to catheter removal demonstrated resolution of the cyst. The average duration of catheter drainage in type 1 pseudocyst is 18 days (range 11-23 days) [8] . Complications reported with percutaneous drainage include infection 8%, pneumothorax 1%, pleural effusion 1% and minor hemorrhage 3% [6] .

Catheter eroding bowel has also been reported with prolonged drainage of more than six weeks [8] .

Surgical drainage, either external for cysts with immature wall or internal in the presence of mature wall, was the only option available for many years. However, percutaneous drainage in type 1 pseudocysts can be as effective as surgery. Furthermore, it can be a safer approach in critically­ill patient and high surgical risk group [6] .

Endoscopic cystoduodenostomy or cystogastro­stomy have been reported using a diathermy needle to penetrate the mucosa into the pseudocyst where it bulges into the lumen of the viscera. After this diathermic puncture, using the same needle, contrast was injected under fluoroscopic control to obtain the best localization and orientation, then using the sphincterotomy wire 1-2 cm opening is created. Nasocystic catheter drainage is inserted for a few days. Complications of this procedure include serious arterial bleeding and pseudocyst infection. Adequate surgical back-up is mandatory. Success rate of 96% for endoscopic cystoduodenostomy and 100% for endoscopic cystogastrostomy were reported. This technique is not effective in the presence of pancreatic duct disruption and technically not feasible if the distance between the viscera and the cyst is more than 1 cm [10],[11] .

In the presence of duct disruption transpapillary drain or stent placement across the disruption or directly into the fluid collection was described. Complications include exacerbation of pancreatitis and stent occlusion leading to recurrent duct blow-out and pseudocyst formation or chronic pancreatitis [12] .

 
   References Top

1.Lewis G, Krige JEJ, Bomman PC, Terblanche J. Traumatic Pancreatic Pseudocyst. Br J Surg 1993;80:89-93.  Back to cited text no. 1    
2.Barkin JS, Ferstenberg RM, Panullo W, Manten HD, Davis RC. Endoscopic retrograde cholangio-pancreatography in pancreatic injuries. Gastrointest Endosc 19882:102-4.  Back to cited text no. 2    
3.Gothi R, Bose NC, Kimar N. Case Report: Ultrasound dem­onstration of traumatic fracture of the pancreas with pan­creatic disruption. Clin Radiol 1993;47:434-5.  Back to cited text no. 3    
4.Leppaniemi A, Haapianen R, Kiriluoto T, Lempinen M. Pan­creatic Trauma: Acute and Late Manifestation. Br J Surg 1988;75:165-7.  Back to cited text no. 4    
5.Carr ND, Cairns SJ, Lees WR, Russell RCG. Late complica­tions of pancreatic trauma. Br J Surg 1989:76:1244-6.  Back to cited text no. 5    
6.Grace PA, Williamson RCN. Modem management of pan­creatic pseudocysts. Br J Surg 1993;80:573-81.  Back to cited text no. 6    
7.Yeo JC, Bastidas JA, Lynch Nyhan A, Fishman KE, Zinner MJ, Cameron JL. The natural history of pancreatic pseudo­cyst documented by computed tomography. Surg Gynecol Obstet 1990:170:411-6.  Back to cited text no. 7    
8.D'Egidio A, Schein M. Pancreatic Pseudocyst: A proposed classification and its management implications. Br J Surg 1991;78:981-4.  Back to cited text no. 8  [PUBMED]  
9.Morali GA, Braverman DZ, Semesh D, Abanoritz Z, Jacob­sohn WZ. Successful treatment of Pancreatic Pseudocyst with a somatostatin analogue and catheter drainage. Am J Gastroenterol 1991;86:515-8.  Back to cited text no. 9    
10.Cremer M, Deviere J, Engelholm L. Endoscopic Management of Cysts and Pseudocysts in Chronic Pancreatitis: Long-term follow-up after seven years of experience. Gastrointest Endosc 1989;35:1-9.  Back to cited text no. 10  [PUBMED]  
11.Donnelly PK, Lavelle P, Carr-Locke D. Massive Hemor­rhage following Endoscopic Transgastric Drainage of Pan creatic Pseudocyst. Br J Surg 1990;77:758-9.  Back to cited text no. 11    
12.Kozarek RA, Ball TJ, Patterson DJ, Freeny PC, Ryan JA, Traverso WL. Endoscopic Transpapillory Therapy for dis rupted Pancreatic Duct and Peripancreatic Fluid collection. Gastroenterology 1991;100:1362-70.  Back to cited text no. 12    

Top
Correspondence Address:
Hassan A El Musharaf
Riyadh Armed Forces Hospital, P.O. Box 7897, Riyadh 11159
Saudi Arabia
Login to access the Email id

Source of Support: None, Conflict of Interest: None


PMID: 19864826

Rights and PermissionsRights and Permissions


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]



 

Top
 
  Search
 
  
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Email Alert *
    Add to My List *
* Registration required (free)  


    Case Report
    Discussion
    References
    Article Figures

 Article Access Statistics
    Viewed3177    
    Printed99    
    Emailed4    
    PDF Downloaded1    
    Comments [Add]    

Recommend this journal