case of pseudocyst of pancreas,diagnosis,mananagement,

1. PEOF.DR.M.S.ELANGOVAN M.S,UNIT
Presented by Dr.saravanan m.s,(p.g)

2. CASE SUMMARY
 42 yr 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 PERSONAL HISTORY
 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,no pallor,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,umblicus in 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 shifting dullness
 AUSCULTATION
BS +

7. INVESTIGATIONS
 CBC
Hb 10.6 gm%,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
SGPT 20u/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 scopy Esophagus,stomach,duodenum normal
 USG abdomen
Pancreas large cyst present in panceatic region
other organs normal

10. INVESTIGATIONS
 CT abdomen
Cystic structure 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 pancreas extends 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 and Roux en y cystojejunostomy under
epidural anesthesia
 Findings
2 cyst of size15*12 & 10*8 cm communicating each
other,attached with omentum

15. PROCEDURE pseudo cyst

16. Separation of sac from omental
attachme nt

17. aspiration

18. Drainage of fluid (1.6 litre)

19. PROCEDURE jejunum resected 20
cm from dj flexure

20. Proximal and distal end of jejunum

21. Closure of distal end of jejunum

22. Cysto jejunostomy

23. Cysto jejunostomy

24. Cysto jejunostomy

25. Jejeno jejunostomy(end to side anastomosis)

26. Jejeno jejunostomy

27. Jejeno jejunostomy

28. Roux en y cystojejunostomy

29. Post operative treatment
 NPO
 IO,BP,TPR chart,
 IVF
 Antibiotics
 Analgesics

30. Fluid analysis
 Culture no 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 of amylase 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
 Communication with main pancreatic duct
Communicating
Noncommunicating
 Number
Single pseudocyst 85%
Multiple pseudocyst

34. Degidio classification
Types Occurrence Communication
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
 Pancreatic abscess
 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
Process Outcomes
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

38. THANK
YOU.