CASE 15435 Published on 12.05.2018

Acute pancreatitis and sinistral portal hypertension complicating pancreatic hydatid cyst

Section

Abdominal imaging

Case Type

Clinical Cases

Authors

Ammor Hicham, Boujarnija Hajar

Ibn Baja Hospital, Department of radiology, Taza Morocco; Email:ammor_hicham@hotmail.com
Patient

19 years, female

Categories
Area of Interest Abdomen ; Imaging Technique CT, Ultrasound
Clinical History

A 19-year-old woman presented to the emergency service with epigastric pain and vomiting for 3 days. She reported no history of jaundice or fever. Abdominal examination revealed a tenderness in the epigastrium. Her serum lipase activity was three times greater than the upper normal limit.

Imaging Findings

Abdominal ultrasound revealed a multilocular anechoic cystic lesion of 43x35 mm in size located in the body of the pancreas communicating with a dilated Wirsung duct.
Abdominal computed tomography (CT) confirmed this finding, and revealed marked atrophy of the pancreatic tail. The cystic lesion was compressing the splenic artery and the splenic vein, causing sinistral hypertension; A dilatation of gastro-omental, short gastric, left and right gastric veins was also detected.
The pancreatic head was enlarged and there was peripancreatic oedema and fluid collection, indicating acute pancreatitis.
A diagnosis of acute pancreatitis complicating a rupture of the hydatid cyst into the Wirsung duct was made.

Discussion

Pancreatic location of hydatid disease is rare (less than 1% of all the sites). [1, 2]
As reported by Dahniya et al. [3], it arose in only 1 of 357 cases of hydatid disease over a 20-year period.
The clinical presentation varies according to the size and the location of the cyst. [4] Cysts located in the body or tail of the pancreas may present as a mass. [5, 6] Uncommonly, they might present with mesenteric vein thrombosis, sinistral portal hypertension related to splenic vein obstruction, rupture into the biliary three or into the peritoneal cavity and abscess formation. [7, 8, 9]
Pancreatic hydatid cysts may cause acute pancreatitis. [10, 11] The mechanism of this complication remains unclear. Two hypotheses are postulated: compression of the Wirsung duct by the cyst [12] or obstruction by hydatid scolices that migrate from the hydatid cyst. [13, 14, 15]
Ultrasound (US) is the most sensitive technique for the detection of the cyst content (membranes, septa and hydatid sand). It may detect a specific sign of hydatid disease represented by floating endocystic membranes.
Computed tomographic (CT) may show rounded cystic lesions associated with calcifications which can grant to make the diagnosis if the clinical setting is fitting. [16] CT will also help assess the severity of acute pancreatitis and to estimate the prognosis. The opening of the cyst in the main pancreatic duct is indicated by the dilation of Wirsung’s canal (as in the case of our patient) and the detachment of the hydatid membrane.
The migration of hydatid material into the main pancreatic duct may be detected by magnetic resonance imaging and endoscopic ultrasound. [15]
The therapeutic modalities depend upon the anatomical localisation of the cyst. Hydatid cysts in the tail of the pancreas may be treated with distal pancreatectomy, those located in the body and head of the pancreas can be treated with proper evacuation, pericystectomy and omentoplasty. [7]
If there is a communication with the Wirsung's duct, cystogastrostomy can be the method of choice; insertion of a stent into the duct during surgery is an alternative treatment option. [17]

Differential Diagnosis List
Rupture of hydatid cyst into the Wirsung duct causing pancreatitis
Pseudocysts
Congenital epithelial cysts
Retention cysts
Lymphoepithelial cysts
Duplication cysts
Final Diagnosis
Rupture of hydatid cyst into the Wirsung duct causing pancreatitis
Case information
URL: https://www.eurorad.org/case/15435
DOI: 10.1594/EURORAD/CASE.15435
ISSN: 1563-4086
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