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Although the pancreas is not a frequent source of major gastrointestinal hemorrhage, bleeding in patients with pancreatitis is not an uncommon complication. In patients with bleeding who are known to have pancreatitis or a pseudocyst, this organ must be considered a possible site of hemorrhage. It is recommended that celiac axis and superior mesenteric artery angiography be performed prior to barium contrast studies. If bleeding is originating from a pancreatic pseudocyst, aggressive surgical intervention should be undertaken. Three cases are described in which prompt operation was successful. Intracystic suture-ligation of the bleeding vessel together with cystogastrostomy was performed in two cases. One case of bleeding from a pseudocyst in the head of the pancreas and involving the gastroduodenal artery was treated by excision of the cyst and head of the pancreas.

The natural history of hereditary pancreatitis has been outlined and another family is presented with this rare disease. In our patient a complicating pancreatic pseudocyst evolved during hospitalization. The development of the pseudocyst and its subsequent course after drainage has been illustrated by serial roentgenograms. Hereditary pancreatitis can be differentiated from other causes of pancreatitis in childhood, and the management of this disease has been indicated.

The records of nine patients referred for evaluation of pancreatic pseudocysts were reviewed. Nearly all presented with the triad of epigastric pain, palpable abdominal mass, and distortion or displacement of the upper gastrointestinal tract on barium study. All nine patients either failed to reveal a pancreatic pseudocyst at laparotomy or had disappearance of the mass at clinical follow-up study. In the last three patients, duodenal endoscopy with retrograde pancreatography was performed. In two of the three patients, normal anatomic structures were identified, which should have alerted clinicians to postpone surgery. In the third patient, abnormalities of the pancreatic duct and gland were sufficient to suggest a mass which later disappeared. We interpreted this to represent the appearance of edematous pancreatitis which resolved with supportive management. The term pseudo-pseudocyst is offered for this group of findings in an attempt to alert the clinician to the importance of diagnosis, the potential reversibility of the transient edema associated with acute pancreatitis which may mimic pseudocyst, and the need to avoid exploratory laparotomy when newer endoscopic technics suggest that surgery may not be indicated.

It has recently been reported that the differential diagnosis of left upper quadrant masses must include intrasplenic dissection of pancreatic pseudocyst ( Warshaw et al, 1972 ). Other than this report, and one article in the French literature ( Moreaux and Bismuth, 1969 ), we have been unable to find any description of this entity. We are presenting such a case in which the diagnosis was suggested primarily by the radiological evaluation.

BRANDENBERG, Maddock and Schweitzer1 reported the treatment by transgastric cyst gastrostomy of 2 patients with pancreatic pseudocysts and pancreatitis in 1951. Maddock suggested this procedure, which had been described in the European surgical literature2 but had not been reported in this country up to that time. The patients mentioned in the 1951 report have remained well, and transvisceral cyst enterostomy or cyst gastrostomy has been performed on 8 more patients. The present report is concerned with these 10 patients, who have been followed for periods up to twelve years. Patients The clinical material consists of 8 patients treated in this . . .

Serious gastrointestinal bleeding is common in patients with chronic pancreatitis and pancreatic pseudocysts. In many instances, the bleeding is the result of other conditions in the gastrointestinal tract such as peptic ulcer disease. However, pancreatic pseudocysts may produce serious gastrointestinal hemorrhage by erosion of adjacent blood vessels. Two cases in which such lesions were associated with bruits were studied angiographically. In each of these cases, an erosive change of the splenic artery was demonstrated.Selective celiac angiography is a safe and simple procedure which may provide the surgeon with valuable information in the management of these difficult cases.

1. The treatment of pancreatic pseudocysts is complex and the election of the method to be utilized depends on the type, size, and localization of the cyst.

The frequency of attacks of pancreatic inflammation in a population where alcoholism and gallbladder disease are common is stressed. During an 18-month period 21 such patients were admitted to the hospital, in all of whom a diagnosis of acute pancreatitis was confirmed on the basis of clinical and laboratory data. Treatment is essentially nonoperative, the principal features being prevention of pancreatic stimulation by gastroduodenal suction, withholding of food, and intravenous feeding. The nonoperative management of chronic pancreatitis and pancreatic pseudocyst is discussed, and the indications for internal drainage procedures are reviewed. Illustrative case histories and radiographs are presented.

Pancreatitis, in common with many other upper abdominal diseases, often leads to pleuropulmonary complications. Radiological evidence of pleuropulmonary abnormality was found in 55% of 58 cases examined retrospectively. The majority of such abnormalities are not specific for pancreatitis; but a particular category of pleural effusions, rich in pancreatic enzymes, is a notable exception. A patient with this type of effusion, complicated by a spontaneous bronchopleural fistula and then by an empyema, is reported. The literature relating to pancreatic enzyme-rich pleural effusions (pathognomonic of pancreatitis) is reviewed. Of several possible mechanisms involved in pathogenesis, transdiaphragmatic lymphatic transfer of pancreatic enzymes, intrapleural rupture of mediastinal extensions of pseudocysts, and diaphragmatic perforation are the most important. The measurement of pleural fluid amylase, at present little employed in this country, has considerable diagnostic value. Enzyme-rich effusions are more commonly left-sided, are often blood-stained, are frequently associated with pancreatic pseudocysts, and—if long standing—may be complicated by a bronchopleural fistula.

Three patients with mediastinal extension of pancreatic pseudocysts are presented. Clinical manifestations included a history of esophageal obstruction and pleural effusion in two patients, and in none of the three could an epigastric mass be palpated. The pseudocysts traversed the diaphragm by way of the esophageal hiatus in two patients and by erosion directly through the diaphragm in the third case. The latter occurrence has never been described before. The diagnosis of mediastinal pseudocyst should be considered in patients with lower mediastinal masses seen on chest roentgenogram, in whom barium studies show displacement of the distal esophagus and stomach by a retrogastric mass. Although the predominant clinical manifestations are related to the chest, proper management should include cystography, laparotomy, and cystenteric anastomoses. Two of our patients underwent thoracotomy and both eventually required laparotomy to cure the pseudocyst. External drainage in two patients was followed by recurrence of the pseudocyst, emphasizing the importance of internal drainage. Although mediastinal extension of a pancreatic pseudocyst, as described in this report, is uncommon, pleural effusion and atelectasis are frequent thoracic complications of pancreatic pseudocysts limited to the abdomen.

An unusual case is presented of a ruptured pancreatic pseudocyst with associated but separate encapsulated pancreatic fluid. Peritonitis was also present and the problems encountered in management of the patient are described. Treatment of pseudocysts of the pancreas is primarily surgical and the advantages and disadvantages of various surgical procedures for this purpose are discussed. The operative technics of internal and external drainage as employed by us are described. It is emphasized that when surgery of a pancreatic pseudocyst is delayed or not carried out, rupture is highly potential, and when complicated by peritonitis, this carries a high mortality.

Four cases of leiomyoblastoma are presented which illustrate the clinical presentations and gross anatomical appearance associated with this type of tumor when it is clinically significant. Case 1 is unique in having a markedly elevated mitotic rate with no evidence of metastasis at autopsy; it is the third case presenting as a pancreatic pseudocyst. Twenty-two cases of leiomyoblastoma reported in the literature since 1962 are reviewed. Experience with varying clinical presentations, gross anatomical and histologic appearances, and results of surgical therapy are summarized. Seven examples of metastasis of this tumor have been reported. In each case the rate of mitosis had significantly increased. Case 1 of our series had a mitotic rate from 2 to 3 times higher than those that metastasized, but no evidence of metastasis was present at autopsy. There may be variants of leiomyoblastomas with elevated mitotic rates that do not metastasize or do so only after a protracted course. Nevertheless, the mitotic rate remains die best criterion for prognosis.

Following several attacks of pancreatitis, recurrent pleural effusions and lung infiltrations over a number of years, the sudden onset of a mechanically caused impairment of cardiac function led to the operative removal of a mediastinal pancreatic pseudocyst, with complete cure, in the thirty-four year old patient described herein. Mediastinal pancreatic pseudocysts are extremely rare. The few cases reported previously provide certain diagnostic criteria of which a careful roentgenologic assessment is of the utmost importance.

Distal pancreatectomy has been performed in sixty patients with pancreatic disruption with pancreatic ductal injury. Included are eight cases in which the injury was located considerably to the right of the superior mesenteric vessels and 13 cm or more of pancreas was resected. Late complications directly attributable to the pancreatic injury and resection were few, with one instance of long-term pancreatic endocrine insufficiency and one pancreatic pseudocyst. Mortality in these cases was 12 per cent and bore a direct relationship to the magnitude of injury to associated organs. Distal pancreatectomy is the treatment of choice for major injury involving the body or tail of the pancreas. It can be a satisfactory treatment for major injury involving the head of the pancreas.

Summary A patient with an intra-abdominal cystic lymphangioma presenting as a pancreatic pseudocyst is reported. The complete surgical excision of this benign lesion could not be performed because of the size and anatomic location.

A pancreatic pseudocyst was delineated using a multiple radionuclide technic. A liver scan using 99mTc sulfur colloid demonstrated extrinsic pressure upon the inferior aspect of the liver. An abdominal blood pool scan using 99mTc pertechnetate outlined the mass exerting the pressure upon the liver. The diagnosis of pancreatic pseudocyst was suggested from these studies. The technic of the studies and the use in evaluating extrahepatic masses are discussed.

Twenty-five consecutive patients with a clinical diagnosis of pancreatic pseudocyst supported by history, an abdominal mass or fullness, elevated serum amylase level, and confirmatory upper gastrointestinal series underwent preoperative examination by ultrasound. On thirteen occasions the ultrasonic configuration of a cyst was present in agreement with the clinical impression. Subsequent exploration or autopsy confirmed the presence of the cyst in ten instances, the remaining patients not coming to exploration. On thirteen other occasions, however, solid tissue was predicted by ultrasound in disagreement with the clinical impression. Nine of these patients came to exploration or autopsy, the ultrasound diagnosis being confirmed in eight. There was one false-negative result. In the eight patients with confirmed diagnoses of solid tissue clinically mimicking pseudocyst but correctly predicted by ultrasound, the mass consisted of peripancreatitic edema. This condition would appear to be more frequent than is generally realized. Unnecessary exploration can be avoided in these patients. The adjunctive uses of this technic in obtaining either natural history or postoperative information are discussed.

Summary The second report in the literature and the first successfully treated case of spontaneous pseudocystoduodenocolostomy is p resented. An attempt has been made to clearly distinguish between spontaneous intraperitoneal rupture of pancreatic pseudocysts and spontaneous perforation into the gastrointestinal tract. Rupture presents as an acute abdominal catastrophe in a patient with a history of pancreatitis and should be treated by external drainage. In the past this complication has produced a mortality of 60 per cent. Perforation presents a picture of abdominal pain, fever, nausea and vomiting, and diarrhea. Treatment varies with the location of the communication, and the over-all mortality should be significantly less than 50 per cent.

The natural history of pancreatic pseudocyst occasionally terminates with rupture into either the peritoneal cavity or a hollow viscus. Rupture into the duodenum, however, is extremely rare; the world literature contains but two documented reports of this complication. 1 This report details the third such case, reviews the pertinent literature, and discusses the radiologic diagnosis. Report of a Case A 46-year-old Negro man was admitted to the Greenpoint Hospital on Dec 29, 1968, with the complaint of epigastric pain and vomiting of two days' duration. He admitted to the daily consumption of large quantities of alcohol and had been hospitalized twice during the preceding year for treatment of acute pancreatitis. Upper-gastrointestinal tract x-ray films were normal during the first admission (Fig 1). At the second admission, nine months before the current hospitalization, repeat examination showed the stomach and duodenal bulb to be intrinsically normal. The entire descending portion of the

Obstructive jaundice in the adult is usually caused by biliary tract calculi or neoplasms, hepatotoxic drugs, and, less commonly, a cholangiolitic form of infectious hepatitis. An uncommon cause is biliary obstruction from a pancreatic pseudocyst. The importance of considering compression of the common bile duct by a cyst in the head of the pancreas is the problem of differentiating this lesion from carcinoma. This separation, often impossible by clinical and laboratory methods, is frequently difficult at the time of laparotomy. The diagnostic and therapeutic aspects of this cause of jaundice are illustrated by the present report. Report of a Case A 52-year-old white, married, male hospital housekeeper, was admitted to the Peter Bent Brigham Hospital for the first time in July, 1957, because of jaundice of three days' duration. A chronic alcoholic, he had been in good health until eight months before admission. Since that time he had noted intermittent

Although pancreatitis is not an uncommon precursor of pancreatic pseudocyst, it is usually the chronic or relapsing form of the disease which gives rise to cyst formation. It is rare for an initial attack of acute necrotizing pancreatitis to lead to the development of pseudocyst. In the following case the rapid development of a large pseudocyst in the wake of an initial attack of severe necrotizing pancreatitis produced almost complete gastric obstruction and required early surgical intervention. Report of a Case A 21-year-old man was brought to the hospital by ambulance. Forty-eight hours prior to admission he had had sudden cramping epigastric pain and nausea, which soon subsided. Five hours prior to admission he again developed sudden severe epigastric pain and a burning sensation, with vomiting. There was radiation of the pain to the middle of the back. His personal and family histories were unrevealing except for excellent general health.

INTERNAL drainage of pancreatic pseudocysts has gradually replaced all other forms of surgical drainage procedures for this condition. Cystogastrostomy is selected for internal drainage when the operative findings indicate that the pseudocyst lies in an advantageous position such that drainage into the stomach will effectively empty the cyst. Though clinical impression has suggested that cystogastrostomy properly selected and performed is an effective surgical treatment for pancreatic pseudocyst, it has always been of interest to ascertain the surgical result. Typically, routine postoperative roentgenograms of the stomach fail to demonstrate reflux radiopaque material through the cystogastrostomy into the cyst, although such visualization may occasionally occur. Recently, the stoma of a cystogastrostomy has been visualized by gastroscopy in the postoperative period.1 In 1931, Jurasz, a German surgeon, described transgastric catheter drainage of a pancreatic pseudocyst2and 13 years later Dos Santos3agreed that this was an ingenious way to follow

A further case of pancreatic pseudocyst with the preoperative diagnosis of renal cyst is reported. A left nephrectomy and a resection of the tail of the pancreas were performed and the patient made a good recovery. There was no suspicion of abdominal trauma, biliary disease, or heavy alcohol intake. Cytology from aspirate revealed no signs of malignant cells. The amylase content was not determined. Despite IVP and selective renal arteriography a correct diagnosis was not obtained preoperatively.