A 34-year-old man was admitted to the Surgery Department in our centre in July 2016 with diffuse abdominal pain, dyspnea, general fatigue, and weakness. In his medical history, he had been admitted to another centre two months ago for an episode of acute pancreatitis.
Abdominal ultrasonography revealed a heterogeneous area of 5 cm in size in the body of the pancreas, peripancreatic fluid, gallstones with thickness in the gallbladder wall, and multiple cysts in the left kidney. Abdominal computed tomography (CT) showed heterogeneous collection of fluid with a thick wall of 12 x 4 cm in size along the body of the pancreas and left colic angle (often an abscess or a pseudocyst) with infiltration of adipose tissue around it and mild thickness at the wall of the colon. A simple renal cyst was also reported in the left kidney (Figure 1).
Laboratory investigations were within normal levels except an elevation in C-reactive protein value (18.1 mg/dl) and amylase (765 U/L). The hepatic tests were within the normal range (total bilirubin (TB) was 0.64 mg/dl, alanine aminotransferase (ALT) was 20 IU/L, and aspartate transaminase (AST) was 19 IU/L). The patient was treated as an episode of acute pancreatitis.
Other investigations were performed; upper gastrointestinal endoscopy (UGI endoscopy) demonstrated an esophagitis (grade A) at the lower esophagus, incompetence of the lower esophageal sphincter (LES), diffuse congestion of the mucous membrane of the stomach, and aphthous ulcer at the fundus of the stomach. Lower GI endoscopy was normal until the terminal ileum.
A month later, the CT scan for thorax and abdomen data were similar to the previous finding, and the pancreatic cyst measuring 13.5 x 7 cm stretched down through the peritoneal cavity in front of the mesenteric vessels.
The laboratory values were normal, and a primary diagnosis of pancreatic pseudocyst was probable, and the decision of surgical intervention was decided.
Intraoperatively, an extreme oedema in the pylorus, the transverse mesocolon, the head and body of the pancreas, and the hepatoduodenal ligament was found. A cholecystitis required cholecystectomy. After entering the lesser sac, a large mass of 35 x 20 x 15 cm in size was found, located in the space between the tail of the pancreas, spleen, left colic angle, left kidney, stomach, and diaphragm. The mass was hard to dissect from the neighboring structures. In puncture, a clear pure liquid was aspirated proposing the existence of a hydatid cyst. Cyst fenestration was performed, and multiple daughter cysts were evacuated; the endocyst membrane was removed (Figure 2). A Foley catheter was placed in the residual cavity. The simple renal cyst needs no intervention according to the urologist. The final diagnosis was pancreatic hydatid cyst.
The patient had another episode of acute edematous pancreatitis after a month of surgery, and the amylase level was over 1000 U/L. The development of local retroperitoneal abscess required puncture and drainage by CT; the patient also developed a deep venous thrombosis and was treated by anticoagulants.
During 18 months of follow-up, the patient was well with no episodes of recurrence or other complications.