PMC4895868_01
Upright plain film at the time of first admission. Although the image of the abdomen was unrevealing on initial read, later inspection identified the suggestion of increased gastrocolic separation in the left upper quadrant (region marked by stars). This separation between the stomach and the transverse colon is consistent with a fluid collection in the lesser sac.
gr1.jpg
PMC4895868_01_gr1.jpg
fig1
ALT were within normal limits. Albumin and total protein were low. A plain film of the abdomen was read at the time as unremarkable (Figure 1).
Scout image from the second admission. The contour of the abdomen suggests massive, tense abdominal distension.
gr2.jpg
PMC4895868_01_gr2.jpg
fig2
On exam, he was jaundiced and had a decreased physical build compared to two months prior in addition to a large tense abdomen (Figure 2).
Ultrasound of the right upper quadrant/epigastric region demonstrates a hypoechoic collection in the region of the head of the pancreas. The suggestion of a tissue wall separates this collection from the ascites fluid in the abdomen.
gr3.jpg
PMC4895868_01_gr3.jpg
fig3
Axial CT slice of the upper abdomen at admission reveals pseudocyst surrounding the pancreas (area of higher attenuation). Despite the anterior spread, pseudocyst continuity with the space posterior to the pancreas confirms the retroperitoneal location of the fluid collection. Pseudocyst boundaries are indicated by thin arrows; note the thin rim suggesting a walled-off collection. The arrowhead highlights the integrity of Gerota's fascia and the perirenal fat, localizing the pseudocyst in the left anterior pararenal space in this region.
gr4.jpg
PMC4895868_01_gr4.jpg
fig4
CT showed a small liver consistent with mild cirrhosis, but no nodularity was present. CT also revealed a large peri-pancreatic cystic structure, measuring 20 by 8 centimeters in its largest anterior-posterior dimension (Figure 4) and extending from the pancreas inferiorly to the level of the iliac crest (Figure 5). The pseudocyst was found in the left anterior pararenal space but not in the perirenal space; Figure 4 demonstrates that Gerota's fascia and the perirenal fat remain intact.
Coronal reconstruction, revealing the body of the pseudocyst in the left anterior pararenal space, extending from the level of the stomach down inferiorly to the iliac crest.
gr5.jpg
PMC4895868_01_gr5.jpg
fig5
CT showed a small liver consistent with mild cirrhosis, but no nodularity was present. CT also revealed a large peri-pancreatic cystic structure, measuring 20 by 8 centimeters in its largest anterior-posterior dimension (Figure 4) and extending from the pancreas inferiorly to the level of the iliac crest (Figure 5).
QuickTime movie of coronally reformatted CT. Note the boundaries of the collection and the suggestion of loculations within it.
gr5a.jpg
PMC4895868_01_gr5a.jpg
fig5a
QuickTime movie of sagittally reformatted CT. Note the boundaries of the collection and the suggestion of loculations within it.
gr5b.jpg
PMC4895868_01_gr5b.jpg
fig5b
CT at the level of gastric emptying into the duodenum, with the pseudocyst (*) visibly compressing the stomach anteriorly and posteriorly.
gr6.jpg
PMC4895868_01_gr6.jpg
fig6
Continuing pseudocyst (*) at the level of the retroperitoneal duodenum. Also note hydronephrosis at the left renal pelvis (arrow).
gr7.jpg
PMC4895868_01_gr7.jpg
fig7
Moderate left hydronephrosis was also seen; the presence of pseudocyst contiguous with the left psoas muscle was consistent with compression of the ureter in this region (Figure 9, Series C).
This sagittal CT reconstruction shows the distended lesser sac pressed anteriorly by the presence of the pseudocyst. (Arrow marks the anteriorly displaced gastrocolic ligament. Stars at the pseudocyst border demonstrate the proximity of the pseudocyst to the transverse colon inferiorly and the stomach superiorly.)
gr8.jpg
PMC4895868_01_gr8.jpg
fig8
After percutaneous drainage and diuresis with furosemide and spironolactone, the patient's abdominal distension (Figure 10) and lower extremity edema decreased significantly with corresponding improvement in his appetite.
Single axial CT slice taken from series C, demonstrating the pseudocyst abutting the anterior surface of the psoas muscle in the region of the left ureter. The arrow indicates the region of interest in series C.
gr9.jpg
PMC4895868_01_gr9.jpg
fig9
Prior to drainage, pseudocyst compression of the inferior vena cava was present (Figure 11).