Table of Contents  
LETTER TO EDITOR
Year : 2018  |  Volume : 28  |  Issue : 2  |  Page : 42-43

An unusual clinical presentation of pancreatic pseudocyst


1 Department of Neurology, Dr. RML Hospital, Delhi, India
2 Department of Medicine, UCMS and GTB Hospital, Delhi, India

Date of Submission18-Feb-2020
Date of Decision04-Apr-2020
Date of Acceptance20-Apr-2020
Date of Web Publication1-Aug-2020

Correspondence Address:
Dr. Abhishek Juneja
A-15, Old Quarter, Back Side, Ramesh Nagar, Delhi - 110 015
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njss.njss_2_20

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How to cite this article:
Juneja A, Jhamb R. An unusual clinical presentation of pancreatic pseudocyst. Niger J Surg Sci 2018;28:42-3

How to cite this URL:
Juneja A, Jhamb R. An unusual clinical presentation of pancreatic pseudocyst. Niger J Surg Sci [serial online] 2018 [cited 2020 Nov 30];28:42-3. Available from: https://www.njssjournal.org/text.asp?2018/28/2/42/291232



To the Editor,

A 40-year-old female patient presented with complaints of increased shortness of breath for 1 month, dry cough, and left pleuritic chest pain for 15 days. The patient had a history of epigastric pain 6 months before the presentation which subsided over 3 months. Two months after the pain subsided, she started developing shortness of breath. Chest X-ray showed a massive left pleural effusion. Her routine investigations revealed hemoglobin of 10.2 g/dl, total leukocyte count: 12,600/dl, erythrocyte sedimentation rate: 68 mm/h, serum creatinine: 1.0 mg/dl, serum glutamic oxaloacetic transaminase/pyruvic transaminase (SGOT/PT): 64/53 U/L, serum calcium: 9.8 mg/dl, serum triglyceride: 113 mg/dl, total cholesterol: 216 mg/dl, and serum amylase: 2130 U/L. Diagnostic thoracocentesis showed a hemorrhagic pleural effusion. The pleural fluid amylase level was very high – 2800 U/L. An intercostal tube was inserted, and about 2 L of hemorrhagic fluid was drained the 1st day. Abdominal and chest computed tomography scan showed a multiloculated collection with peripherally enhancing thick walls in the left hemithorax with intercostal drain (ICD) tube in situ. The collection was seen to extend from the left hypochondrium into the left hemithorax along the lateral pleural margin through a rent in the left hemidiaphragm measuring approximately 3.5 cm. A well-defined hypodense cystic lesion with peripherally enhancing thick walls in the lesser sac measuring 9.0 cm × 6.8 cm was seen. The lesion was anteriorly abutting the pylorus of the stomach, posteriorly the tail of the pancreas with surrounding mesenteric fat stranding the bulky tail of the pancreas highly suggesting pseudocyst [Figure 1]. The patient was managed nonoperatively for 3 weeks. The ICD output gradually decreased, and serial chest radiographs showed a complete resolution of left pleural collection. The patient later underwent surgical internal drainage for the residual abdominal collection and was discharged from the hospital in stable condition after a month.
Figure 1: Contrast-enhanced computed tomography chest and upper abdomen showing a hypodense lesion in relation to the pancreas communicating with the left hemithorax through a diaphragmatic rent

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Pancreatic pseudocyst is a type of cystic tumor that most commonly occurs as a complication of acute or chronic pancreatitis.[1],[2] Pancreatic pseudocyst can result in pleural effusion, commonly left sided, through various proposed mechanisms, such as direct fluid leakage and reactive effusion.[3] Pancreatic pseudocyst presenting as massive pleural effusion is an extremely rare entity. In these cases, the diagnosis is established by studying the character of pleural fluid, especially the concentration of amylase. Amylase levels in pleural fluid secondary to pancreatic pseudocyst is very high.[4] Treatment options include chest drainage, endoscopic therapy, and surgical therapy.[5] The management of underlying diseases, such as pancreatitis and pancreatic injuries, is equally important. We treated the pancreatic pseudocyst with external drainage. It is likely to recur because of the persistent presence of diaphragmatic rent. The patient is being followed up regularly for any recurrence.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Weledji EP, Ngowe MN, Mokake DM, Verla V. Post-traumatic pancreatic pseudocyst managed by Roux-en-Y drainage. J Surg Case Rep 2015;2015:1-4.  Back to cited text no. 1
    
2.
Zhang Y, Zhang SY, Gao SL, Liang ZY, Yu WQ, Liang TB. Successful resolution of gastric outlet obstruction caused by pancreatic pseudocyst or walled-off necrosis after acute pancreatitis: The role of percutaneous catheter drainage. Pancreas 2015;44:1290-5.  Back to cited text no. 2
    
3.
Hirosawa T, Shimizu T, Isegawa T, Tanabe M. Left pleural effusion caused by pancreaticopleural fistula with a pancreatic pseudocyst. BMJ Case Rep. 2016;2016:bcr2016217175.  Back to cited text no. 3
    
4.
Saraya T, Light RW, Takizawa H, Goto H. Black pleural effusion. Am J Med 2013;126:641.  Back to cited text no. 4
    
5.
Chang YC, Chen CW. Thoracoscopic drainage of ascending mediastinitis arising from pancreatic pseudocyst. Interact Cardiovasc Thorac Surg 2009;9:144-5.  Back to cited text no. 5
    


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