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Pseudocyst of pancreas
- 1. PEOF.DR.M.S.ELANGOVAN M.S,UNIT Presented byDr.saravanan m.s,(p.g)
- 2. CASE SUMMARY 42yr old male presented with complaints of abdominal pain for 20 days more over epigastric to left hypochondrium H/o vomiting No h/o abdominal distension,fever,hematemesis,melena,trauma, constipation No h/o urinary symptoms No h/o loss of wt/appetite
- 3. PAST AND PERSONALHISTORY H/o abdominal pain for the past 6 months on and off was diagnosed as a case of pancreatitis and treated No h/o previous surgeries,jaundice Not a known DM,HT,ASTHMA,TB,CAHD,EPILEPTIC Known alcoholic past 20 years Smoker for 20 years
- 4. ON EXAMINATION Conscious,oriented,afebrile,nopallor,not icteric,no clubbing,no cyanosis,no pedal edema CVS-S1S2 + RS-bilateral air entry + CNS-No focal neurological deficit
- 5. P/A INSPECTION Not distented,umblicusin midline,all quadarents equally moves with respiration,skin normal, no vip,vgp,hernial orifices free,ext genitalia normal,supra clavicular fossa free PALPATION Soft,not warm,mild tenderness present over epigastric and left hypochondrium, VAGUE MASS PALPABLE over epigastric,left hypochondrium of size 8*8 cm No guarding,no rigidity
- 6. P/A PERCUSSION No shiftingdullness AUSCULTATION BS +
- 7. INVESTIGATIONS CBC Hb 10.6gm%,Tc 5800,DC p63% L33% E 04% RBC 3.4 million cumm,platelet 4.7 lakh pcv 31% BT 1 minute CT 2 min 30 sec RBS 95 mg/dl Urea 32 mg/dl Sr creatinine 1.0 mg/dl
- 8. INVESTIGATIONS LFT SGOT 24u/l SGPT20u/l Sr bilirubin total 0.8mg conjugated 0.3mg% un conjucated 0.5mg% Sr.ALP 49u/l,Sr protein 6.5 gm%
- 9. INVESTIGATIONS UGI scopyEsophagus,stomach,duodenum normal USG abdomen Pancreas large cyst present in panceatic region other organs normal
- 10. INVESTIGATIONS CT abdomen Cysticstructure noted along the head and tail of pancreas with multiple parenchymal calcification Cyst from tail exends along the oesophageal hiatus Cyst noted in the lesser sac extends along the entire lt flank measuring 20 cc in the craniocaudal direction IMP; Chronic pancreatitis with multiple pseudocyst one extends along the oesophageal hiatus noted in the post mediastinum
- 11. DIAGNOSIS Pseudocyst of pancreasextends to mediastinum
- 12. TREATMENT NPO IVF Antobiotics Anelgesics Inj.octeriotide 100mic sc bd
- 13. Pre operative instructions Consent NPO since 2 pm Inj TT 0.5cc im Inj Lignocaine test dose Parts preparation Bowl preparation stomach wash at 10 pm&2am Enema 9 pm & 4 Am
- 14. Treatment Procedure Laprotomy andRoux en y cystojejunostomy under epidural anesthesia Findings 2 cyst of size15*12 & 10*8 cm communicating each other,attached with omentum
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- 16. Separation of sacfrom omental attachme nt
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- 18. Drainage of fluid(1.6 litre)
- 19. PROCEDURE jejunum resected20 cm from dj flexure
- 20. Proximal and distalend of jejunum
- 21. Closure of distalend of jejunum
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- 25. Jejeno jejunostomy(end toside anastomosis)
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- 28. Roux en ycystojejunostomy
- 29. Post operative treatment NPO IO,BP,TPR chart, IVF Antibiotics Analgesics
- 30. Fluid analysis Cultureno growth Lipase 236u/l Staining GPC,GPB,GNB,GNC,AFB Negative pus cells nil Cytology Scattered lymphocytes,occasional reactive mesothelial cells admixed with macrophages in a proteinacious background,no evidence of malignancy.
- 31. Discussion Definition collection ofamylase rich fluid in a wall of fibrous or granulation tissue Etiology Following attack of 1)acute pancreatitis 2)chronic pancreatitis 3)pancreatic trauma
- 32. SITES Lesser sac In relation to Duodenum Jejunum Colon Splnic hilum
- 33. Types Duration Acute Chronic Communicationwith main pancreatic duct Communicating Noncommunicating Number Single pseudocyst 85% Multiple pseudocyst
- 34. Degidio classification Types OccurrenceCommunication with duct Type 1 After attack of acute pancreatitis Normal duct anatomy No fistula TYPE 2 Acute on Chronic pancreatitis Abnormal duct anatomy with out sriture 50% chances of fistula Type 3 Chronic pancreatitis Abnormal duct anatomy with sriture Always communicating
- 35. Differential diagnosis Pancreaticabscess Cystic adenocarcinoma Cyst in liver Mesentric cyst Hydatid cyst Aortic aneurism
- 36. Indications for surgery Size of more than 6 cm Infected pseudocyst Persisting pain Pressure effects
- 37. Complecations of cyst ProcessOutcomes Infection Abscess Systemic abscess Rupture into the gut into the peritonium GI bleeding,fistula peritonitis Enlargements pressure effects pain Obstructive jaundice,bowl obstructon Erosion into a vessel Haemorrage into the cyst haemoperitoneum
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