Pseudocyst Pancreas - history, examination approach, diagnosis

Pseudocyst pancreas

1. N a m e : S h a s h i k umar A g e : 3 2 y e a rs S e x : M a l e O c c u p a tion : D a i l y w a g e w o r k e r A d d ress : M a n d y a E d u c ation : N o F o r m a l E d u cation S o c i o economic S t a t u s : C l a s s 5 ( M o d i f i e d B G P r a s a d C l a s s i f ication ) D a t e o f A d m i ssion : 1 5 / 5 / 2 2 1 D a t e o f E x a m ination : 1 7 / 5 / 2 2 1 C h i e f C o m p l a ints : S w e l l i n g i n t h e u p p e r p a r t o f t h e a b d o m en s i n c e 1 m o n t h

2. H i s t o r y of P r e s e n t ing I l l n ess : P a t i e n t w a s a p p a r ently n o r m a l 2 m o n t h s b a c k a f t e r w h i c h h e d e v e l oped p a i n i n t h e upper p a r t o f t h e a b d o m e n , s u d d e n i n o n s e t a n d p r o g r e s sive . T h e p a i n w a s c o n t i n u o us a n d c o l i c k y i n n a t u r e . T h e p a i n r a d i a t e d t o t h e b a c k , a g g r a vat e d w i t h f o o d i n t a k e a n d relieve d o n b e n d i n g f o r w a r d a n d o n medication . P a i n w a s a s s o ciated with n a u s e a a n d v o m i t i ng . P a t i e n t w a s a d m i tted t o M I M S f o r a w e e k a n d w a s t r e ated for the same . P a t i e n t now c o m p l a i n s o f a s w e l l i ng i n t h e c e n t r a l p a r t o f u p p e r a b d o m e n since 1 m o n t h , insidious o n s e t a n d p r o g r e s s ive . I t w a s i n i t ially t h e s i z e o f 2 × 2 c m a n d h a s p r o g r e ssed t o t h e p r e s e n t s i z e o f a p p r o ximately 7 × 7 c m . N o a g g r a vat i n g a n d r e l i e v i ng f a c t o r s . A s s o ciated with d e c r e a sed a p p e t ite N o history of f e v e r N o h i s t o r y o f y e l l o w i s h d i s c o l o ration o f e y e s a n d u r i n e . N o history of h ematemesis . N o h i s t o r y o f t r a u m a . N o h i s t o r y o f w e i g ht l o s s

3. P a s t H i s t ory : N o h i s t o r y o f s i m i l a r i l l n e s s i n t h e p a s t N o h i s t o r y o f p r e v i ous s u r g e r i e s N o h i s t o r y o f h y p e r t ension , d i a b e tes , t u b e r c u l osis , a s t h m a o r e p i l epsy . F a m i l y H i s t ory : N o h i s t o r y o f s i m i l a r c o m p l a i n t s i n t h e f a m i l y N o h i s t o r y o f h y p e r t ension , d i a b e tes , t u b e r c u l osis , a s t h m a o r e p i l epsy . P e r s o n a l H i s t ory : D i e t : M i x e d A p p e t ite : R e d u c e d S l e e p : N o t d i s t u r b ed B o w e l a n d B l a d d er h a b i t s : R e g u l a r C h r o n i c s m o k e r s i n c e 2 y e a r s ( 1 p a c k b e e d i s p e r d a y ) C h r o n i c a l c o h o lic s i n c e 1 5 y e a r s ( 1 8 m l B r a n d y p e r d a y )

4. D i f f e r e n t ial D i a g nosis : P s e u docyst of pancreas E p i g a stric h e r n i a A o r t i c a n e u rysm C ystadenoma of pancreas Cystadenocarcinoma of pancreas Hydatid cyst of pancreas Hydatid cyst of liver Simple cyst of liver M e s e n t e r ic c y s t

5. G e n e r al P h y s i cal E x a m i n ation : A 3 2 y e a r o l d m a l e m o d e r a t e l y b u i l t a n d n o u r i s h e d , c o n s c i ous , c o o p e r a tive a n d well o r i e n ted t o t i m e , p l a c e a n d p e r s o n . P a l l o r Icterus C y a n o s i s C l u b b i ng G e n e r a l i zed l y m p h a d enopathy E d e m a A b s e n t V i t a l s : P a t i e n t i s a f e b r ile R e s p i r a t o r y r a t e : 1 8 c p m B l o o d P ressure : 1 2 4 / 8 2 m m H g ( r i g h t a r m s i t t i ng p o s ition ) P u l s e R a t e ( R i g h t r a d i a l a r t e r y , s i t t i n g ) : 7 b p m , r e g u l a r , g o o d v o l u m e , n o r m a l c h a r a cter , a l l o t h e r p e r i p heral p u l s e s f e l t

6. A b d o m i n al E x a m i nation : I n f o r m e d c o nsent o b t a ined . P a t i e n t i s e x p o s e d f r o m t h e n i p p l e t o t h e k n e e a n d i s e x a m i n e d i n s u p i n e p o s ition w i t h p a r t i a l f l e x i o n o f h i p a n d k n e e j o i n t i n a w e l l l i t r o o m . I n s p ection : A b d o m e n i s n e i ther r e t r a c t ed n o r d i s t e n ded A s p h e r i cal s w e l l ing i s s e e n i n t h e e p i g a s tric a n d u m b i l i cal region , a p p r o ximately m e a s u r i ng 7 × 7 c m w i t h s m o o t h s u r f a c e a n d w e l l d e f i n e d b o r d e r . T h e s w e l l ing e x t e n d s a p p r o x i m ately 5 c m f r o m t h e x i p h i sternum t o 3 c m a b o v e t h e umbilicus v e r t i c a l ly a n d f r o m l e f t m i d c l a v i c u l a r l i n e t o a p p r oximately 3 c m t o t h e r i g h t o f m i d l i n e . N o c o u g h i m p u l s e S k i n o v e r s w e l l ing i s n o r m a l .

7. Umbilicus i s c e n t r a l a n d i n v e r t ed A l l r e g i o n s o f a b d o m e n m o v e e q u a l l y w i t h r e s p i r a t ion N o d i l a t e d v e i n s , sc a r s o r s i n u s e s N o v i s i b l e p e r i s t a lsis o r p u l s a t i o n N o p i g m e n t a t ion o f s k i n H e r n i a l o r i f i c es a r e normal L e f t s u p r a c l a v i c u l a r f o s s a i s n o r m a l E x t e r n a l g e n i t a l ia a r e n o r m a l

8. P a l p a tion : S u p e r f i c ial p a l p a t i o n N o l o c a l r i s e o f t e m p e r a ture N o t e n d e r n ess S w e l l i n g p a l p a ble i n e p i g a s tric a n d u m b ilical region , g l o b u l a r s h a p e a n d o f s i z e 8 × 8 c m , s m o o t h s u r f a c e , c y s t i c c o n s i s t e n c y a n d we'll d e f i ned borders S w e l l i n g e x t e n d s v e r t i c a l ly 5 c m f r o m x i p h i s t e r n u m t i l l 3 c m a b o v e u m b ilicus a n d h o r i z o n t a lly e x t e n d s f r o m l e f t m i d c l a v i c u l a r l i n e t o 3 c m t o t h e r i g h t o f m i d l i n e . S w e l l i n g d o e s n o t m o v e w i t h r e s p i r a tion , n o t m o b i l e a n d n o n p u l s a t i l e . N o f l u i d t h r i l l Carnett's test: S w e lling decreases in size on raising both extended legs from bed. D e e p p a l p a t i o n N o t e n d e r n e s s N o h e p a t o s p l e n o m e g a l y N o k i d n e y e n l a r g e m e nt

9. P e r c u s sion R e s o n a n t n o t e a l l o v e r t h e a b d o m e n a n d s w e l l i ng N o s h i f t i ng d u l l n e s s Liver dullness heard from 6 th ICS to costal margin in r i g h t m i d a x illary line Splenic dullness from th ICS to 1 th ICS in left midaxillary line A u s c u l t a t i o n N o r m a l b o w e l s o u n d s h e a r d S y s t e m ic E x a m i nation C a r d i o vascular system : S 1 , S 2 h e a r d ; N o m u r m ur s R e s p i ratory system : N o r m a l v e s i c u l ar b r e a t h s o u n d s ; N o a d d e d sounds Central N e r v ous system : N o s e n s o r y o r m o t o r d e f i c i t

10. P r o v i s i o n a l D i a g n o sis : P s e u d o cyst of P a n c r e as M a n a g ement : I n v e s tigatio n s : U l t r a s o und a b d o m e n C T s c a n M R C P a n d E R C P E n d o s o n o g r a p h y g u i d e d a s p i r a tion a n d a n a l y s is o f f l u i d f o r A m y l a s e ( e l e v a t e d ) a n d C arcinoembryonic antigen ( n o r m a l ) . L F T , S e r u m a m y l a s e , P l a t e l et c o u n t , P r o t h r ombin t i m e B a r i u m m e a l ( l a t e r a l v i e w ) - N o t u s u a l l y d o n e n o w

11. T r e a t ment : C o n s e r vative : O b s e r v a t i o n a n d f o l l o w u p ( r e p e a t U S G ) f o r p s e u d o cyst s l e s s t h a n 6 c m 2 . I n t e r v e ntio n a l : E n d o s c o pic / E U S / U S g u i d e d d r a i nage a . T r a n s p a p i l l a r y ( f o r c o m m u n i c a t i n g p s e u d o c ysts ) b . T r a n s m u r a l e n d o s c o p ic / E U S g u i d e d s t e n t p l a c e m ent c . P e r c u t a n e ous d r a i n age u n d e r U S G g u i d a nce 3 . S u r g i c a l d r a i nage : O p e n o r L a p r o s c o p i c C y s t o g a s t o s t o m y C y s t o d u o d enostomy C y s t o j e junostomy