Perirenal pancreatic pseudocysts: diagnostic management

Pancreatico-renal fistula associated with pancreatic cysts caused by type 1 autoimmune pancreatitis

To our best knowledge, the formation of a pancreatico-renal fistula and the presence of pancreatic fluid collection in the renal subcapsular space have not been reported as autoimmune pancreatitis (AIP) complications. We describe a case of a pancreatico-renal fistula associated with type 1 AIP. The patient presented with abdominal and back pain accompanied by pancreatic cystic lesions during an untreated course of AIP. The diagnosis of pancreatico-renal fistula was based on the presence of a left renal subcapsular fluid collection containing pancreatic amylase, disappearance of pancreatic cysts, and a defect in the partial anterior renal fascia observed on imaging studies. Treatment with steroids and percutaneous drainage resulted in improvement. Pancreatic pseudocysts can affect other organs owing to their digestive action. Similar symptoms may occur in patients with AIP.

Outlandish pancreatic pseudocyst: A case report

Pseudocysts in the perinephric region are rare and pose a diagnostic dilemma. We present the case of a 54-year-old male with left perirenal pancreatic pseudocyst. The diagnosis was enabled via proper clinical history taking and imaging investigations. The patient was successfully managed with definitive primary surgical treatment. This report highlights difficulties in diagnosis and treatment.

Clinical manifestations, imaging features, and endoscopic management of renal pseudocysts: a case series

Background

Renal pseudocysts (RP) are rare and we know little about their presentation and management. In the present case series, we present the pertinent clinico-radiological features as well as the role of endoscopic drainage in symptomatic RP.

Methods

A retrospective analysis was performed of patients with RP seen in our unit over the last 12 years. Patient symptoms, imaging findings and details of endoscopic or endoscopic ultrasound (EUS)-guided drainage procedures were evaluated.

Results

Eight patients with RP (7 male; mean age: 33.1 years) were studied. Seven patients had underlying chronic pancreatitis (calcific in 3), predominantly alcohol-related. The mean size of the RP was 8.5 cm. All patients presented with abdominal pain and none had urinary complaints. The RP could be well detected on both contrast-enhanced computed tomography and EUS. None of the patients had significant debris on EUS. Five patients were treated with combined transmural and transpapillary drainage, 2 patients were treated with transpapillary drainage alone, while combined percutaneous and transpapillary drainage was performed in 1 patient. All patients had partial disruption of the main pancreatic duct and a bridging transpapillary endoprosthesis was successfully placed. The RP resolved in all patients within 2-6 weeks and no patient required surgery. There were no complications and no patient had recurrence of RP over a follow-up period of 3-118 months.

Conclusion

RP are usually associated with abdominal pain and do not cause renal symptoms. Endoscopic drainage is a safe and effective minimally invasive management option for RP.

Page kidney due to a renal pseudocyst in a setting of pancreatitis

Pancreatic pseudocysts are notorious for their extension beyond the normal confines of the pancreatic bed due to dissection of the enzymatic pseudocyst fluid along fascial planes. Such collections of pancreatic juice may compress the kidney. Extension of the pseudocyst into the perirenal space is, however, uncommon. We report a case of pseudocyst of pancreas lying in the subcapsular plane of the left kidney with a patent communication with the pancreatic duct (pancreaticorenal fistula). The compressive effect of the pseudocyst on the kidney compromised intrarenal perfusion as evidenced by a faint nephrogram but a normal renal artery. This led to renin-angiotensin-aldosterone mediated hypertension-the Page kidney phenomenon. Extensive literature search revealed our case to be the only one to describe such an occurrence.

Renal subcapsular fluid collection caused by penetration of a pancreatic pseudocyst

A 63-year-old man presented with left flank pain and spiked fever. Computed tomography revealed a pancreatic cyst and left renal subcapsular fluid collection that appeared to be connected to the cyst. High levels of amylase and lipase were observed in a test puncture of renal fluid collection. The cause of the fluid collection was diagnosed as penetration of the pancreatic pseudocyst. Endoscopic nasobiliary drainage was used to drain the pancreatic pseudocyst and renal subcapsular fluid collection. The present case demonstrated that renal subcapsular fluid collection may be caused by penetration of a pancreatic pseudocyst.

Proteolytic activity in pancreatic pseudocyst fluid

Pancreatic pseudocyst fluids from 15 patients were biochemically analyzed, especially concerning proteolytic activity and protease inhibitors, and correlated to the clinical course. The pseudocyst fluid was a mixture of pancreatic juice and plasma possessing a high proteolytic activity against high- as well against low-mol-wt proteins. There was practically no functional protease inhibitory capacity left, although immunoreactive inhibitors were present. No distinct biochemical findings differed between fluids from "acute" or from "chronic" pseudocysts. It is concluded, that high proteolytic activity within a pancreatic pseudocyst could well explain symptoms as well as complications caused by the pseudocyst. Biochemical analysis of the pseudocyst fluid cannot, however, be used to differentiate between pseudocysts with a harmless or a complicated course.

Psoas muscle pancreatic pseudocyst: CT--US diagnosis and percutaneous drainage

We present 2 cases of psoas muscle pancreatic pseudocysts. In both cases there was no clinical or laboratory evidence of recent acute pancreatitis. The route of extension for the pseudocyst from the pancreas to the psoas was the perirenal space. In both cases the diagnosis was made on the basis of imaging studies and the pseudocysts resolved with percutaneous drainage only.

Pancreatic pseudocyst fluid--a mixture of plasma proteins and pancreatic juice possessing a high proteolytic activity

Pancreatic pseudocyst fluid from eight patients was examined biochemically. The fluid was found to be a mixture of plasma proteins and pancreatic juice, possessing a high proteolytic activity against high- as well as low-molecular-weight proteins. The proteolytic activity was found to be trypsin-, kallikrein- and plasmin-like. Gel filtration studies showed proteolytic activity to be present corresponding to alpha-2-macroglobulin-bound proteases and also to free proteases. Quantitative immunochemical levels were about 30-100% of normal plasma levels for alpha-2-macroglobulin, C1 inhibitor, antithrombin III and alpha-2-antiplasmin. However, there was practically no functional inhibitory capacity left in the pseudocyst fluid, except for alpha-1-protease inhibitor, which retained its inhibitory capacity. Neither native kininogen nor complement factor C3 was found: this was probably a result of the proteolytic activity. It is concluded, that a continuing proteolytic activity within the pseudocyst, although decreasing with aging of the cyst, could explain symptoms and complications caused by the pseudocyst.

Management of pancreatic pseudocysts in children

The management of 25 children with pseudocyst of the pancreas presenting over a 30-year period is reviewed. Nearly a third could be managed nonoperatively, monitoring clinical signs, serum amylase, and in recent years the findings of ultrasound and CT scan. Persistence of symptoms, signs, and hyperamylasemia for more than 4 weeks indicated failed resolution in all but one case. Endoscopic retrograde cholangiopancreatography (ERCP) done in those who did not improve spontaneously facilitated operative strategy. Early operation and internal drainage in selected cases was well tolerated. Individualization of treatment is emphasized.

Pancreatic lesions and transfascial perirenal spread: computed tomographic demonstration

Computed tomographic (CT) findings in 105 cases of pancreatitis and 107 cases of pancreatic carcinoma were analyzed retrospectively to determine the occurrence and roentgenologic signs of penetration of the anterior renal fascial planes in relation to clinical symptoms. In pancreatitis, the perirenal fat was infiltrated in 7% to variable extents by extrapancreatic fluid collections, either as asymptomatic fluid lying alongside renal fascial planes and perirenal septa (5 cases) or as well-circumscribed fluid collections causing clinical symptoms (2 cases). In pancreatic carcinoma the occurrence of retropancreatic extension to a perirenal space was rarer (3%). Distinction on CT between perirenal involvement from the pancreas and primary adrenal or renal lesions with anterior spread can prevent unnecessary surgery.

Pancreatic pseudocysts: a biochemical evaluation of proteases and protease inhibitors in plasma

A biochemical evaluation was performed on plasma from eight patients developing a pancreatic pseudocyst during acute pancreatitis attacks and from six patients with a known pseudocyst. Patients developing an acute pancreatic pseudocyst had high levels of activated trypsin in complex with alpha 1-protease inhibitor, together with a probable activation of the kinin, complement, coagulation and fibrinolytic systems. Profound changes were also seen in several protease inhibitors, indicating consumption of the inhibitors. The changes did, however, not differ from those seen in severe acute pancreatitis attacks in which no pseudocyst developed. Patients with chronic pancreatic pseudocysts had biochemical changes similar to those seen in moderate pancreatitis attacks, without any overt cascade system activation. At convalescence, however, these patients had biochemical signs of leakage from the pancreas and an ongoing proteolytic activity.