Medical Journal of Dr. D.Y. Patil Vidyapeeth

CASE REPORT
Year
: 2012  |  Volume : 5  |  Issue : 1  |  Page : 66--68

Isolated pancreatic hydatid cyst: Preoperative prediction on contrast-enhanced computed tomography case report and review of literature


Abhijit Rayate, Ramkrishna Prabhu, Chetan Kantharia, Avinash Supe 
 Department of Surgical Gastroenterology, Seth G S Medical College and K E M Hospital, Mumbai, India

Correspondence Address:
Avinash Supe
Department of Surgical Gastroenterology, Seth G S Medical College and K E M Hospital, Mumbai - 400 012
India

Abstract

A primary pancreatic-isolated hydatid cyst, that too in tail of pancreas with no lesion in liver, is a rare presentation of this disease. We report a case of 30-year-old lady presenting with only abdominal pain and on imaging found to be a cystic lesion in tail of pancreas without any liver lesion. Contrast-enhanced computed tomography scan is helpful in diagnosis by identifying the presence of multiloculation, curvilinear calcification, or the presence of daughter cysts. She was successfully treated by distal pancreatectomy without splenectomy.



How to cite this article:
Rayate A, Prabhu R, Kantharia C, Supe A. Isolated pancreatic hydatid cyst: Preoperative prediction on contrast-enhanced computed tomography case report and review of literature.Med J DY Patil Univ 2012;5:66-68


How to cite this URL:
Rayate A, Prabhu R, Kantharia C, Supe A. Isolated pancreatic hydatid cyst: Preoperative prediction on contrast-enhanced computed tomography case report and review of literature. Med J DY Patil Univ [serial online] 2012 [cited 2020 Jan 27 ];5:66-68
Available from: http://www.mjdrdypu.org/text.asp?2012/5/1/66/97519


Full Text

 Introduction



Hydatid disease, although rare, has considerable prevalence in endemic areas dealing with stock-breeding. Although for Echinococcus granulosus, the most common target is liver and lungs, primary hydatid disease can be detected anywhere in body including spleen thyroid, breast, brain, kidney, free abdominal area as well as retroperitonium. [1],[2],[3] Pancreatic involvement of hydatid disease is very rare with an incidence of <1% as compared to other sites of hydatid disease. [1]

 Case Report



A 30-year-old lady presented with dull aching abdominal pain in peri-umbilical region and not associated with vomiting or fever. The pain was not related to meals and without diurnal variations. The pain was relieved by "over the counter" analgesics. There was no weight loss or anorexia. On examination, the abdomen was soft with no palpable abdominal masses. Plain abdominal X-ray was normal. There was no eosinophilia. The ultrasonography of the abdomen revealed a 5 cm cystic lesion in lesser sac behind stomach, liver normal, and no other cystic lesion in abdomen. The contrast-enhanced computed tomography (CECT) scan of the abdomen and pelvis revealed cystic lesion of size 6.2 × 5.7 × 4.5 cm in retroperitonium adjacent to tail of pancreas with disrupted membranes within. No significant fat stranding. Liver and rest of abdomen were normal [Figure 1] and [Figure 2]. Preoperative diagnosis of the hydatid cyst was made based on CT scan by identifying the presence of multiloculation, curvilinear calcification, or the presence of daughter cysts/membranes. ELISA test for Echinoccocus granulosus was positive.{Figure 1}{Figure 2}

Albendazole was started pre-operatively. At laparotomy, lesser sac was opened. A single thick-walled cyst was seen in the tail of pancreas not adhered to adjacent structures (mesentery, spleen, colon, stomach). There was no evidence of any other suspicious cystic lesion neither in liver nor in rest of peritoneal cavity. The cystic lesion was avascular. Splenic artery and vein were easily isolated from the tail of pancreas and only distal pancreatectomy was done. There was no spillage. Drain kept in lesser sac had no output. Albendazole started with oral feeding and continued according to WHO regime. The post-operative period was uneventful. Histopathology revealed on gross, a grey white color cyst of size 6 × 6 × 3 cm with surrounding raw pancreatic parenchyma, while on cutting tender coconut like structures like daughter cysts were seen. Microscopy showed lamellated, acellular eosinophilic material with dense fibrocollagenous tissue on the outer aspect forming the pericyst. It has mononuclear cell infiltrate also. Periphery showed normal pancreatic parenchyma.

With a follow up of 7 months, the patient is totally asymptomatic and has good quality of life. Ultrasonography after 6 months is normal.

 Discussion



Pancreatic infestation by Echinococcus granulosus, is mainly by the hematological route, or peripancreatic lymphatic invasion, but very rarely by retroperitoneal spread; even local spread via the pancreatic or bile ducts has been suggested. [4] Symptoms vary according to anatomical location in pancreas ranging from an asymptomatic disease, abdominal mass, obstructive jaundice, acute and recurrent pancreatitis, and portal hypertension. [5] The differential diagnosis of cystic lesions of the pancreas is extensive and includes pseudocysts, cystic neoplasms, such as serous and mucinous cystadenomas, cystadenocarcinomas, cystic islet cell, and papillary cystic and solid tumors, and other rare tumors. [6] Diagnosing a hydatid cyst of pancreas preoperatively is difficult due to its rarity but CT scan is helpful in identifying the presence of multiloculation, curvilinear calcification, or the presence of daughter cysts. Intraoperative biopsy and histological examination of biopsy material may fail to differentiate cystic lesions reliably in 20% of cases. A biopsy of the wall of a cystic neoplasm of the pancreas is unreliable because serous cystadenoma and mucinous cystic neoplasms have incomplete cyst epithelium in 40% and 72% of cases, respectively. Up to 90% of the cyst lining may be epithelium-free. In addition, some tumors have a mixture of cuboidal, benign columnar, and malignant cells within the same lesion. Aspiration of cyst fluid for scolices may be negative. These data provide a cogent argument in favor of complete excision of an unidentified cystic lesion of the pancreas. [6],[7] Depending on the site, various methods of surgical treatment have been used. For cysts located in the body and tail, subtotal cystectomy leaving only adventia behind is preferred. If a cyst is communicating with MPD then distal pancreatectomy is the procedure of choice, or cystoenteric anastomosis can be done. Cysts located in the head of pancreas have been treated by various methods like Whipple's resection, marsupialization, and external drainage. Other methods like partial cystectomy or cystoenteric anastomosis have also been used. [6],[8],[9],[10] There are few reports in the literature in which a cyst in the tail of pancreas was managed by distal pancreatectomy with splenectomy. [11] We were successfully able to spare the spleen in this patient.

We conclude that a hydatid cyst should be considered a differential diagnosis in management of complex cystic lesions of pancreas. Typical features identified in CECT are helpful in making preoperative diagnosis and appropriate treatment.

 Acknowledgement



Dr. Sanjay Oak, Director, Seth G S Medical College, Mumbai, India.

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