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RADIOLOGY: PANCREAS: Case# 103: HEMORRHAGIC PANCREATITIS AND DUOD. WALL PSEUDOCYST. This is a 46 year old male with a history of alcohol abuse and acute pancreatitis. Inflammatory changes and fluid surround the pancreas within the anterior pararenal space. A more well defined fluid collection in continuity with the second and third segment of the duodenum suggests that fluid may have dissected within the serosa of the second and third duodenal segments. There are strands of high attenuation within this fluid collection on the pre-contrast study, suggesting hemorrhage. There is moderate gaseous and fluid distention of the stomach suggesting at least partial obstruction at the duodenum. A moderate left pleural effusion with associated left lower lobe atelectasis is present. The liver is diffusely diminished in attenuation without evidence of focal lesion. Strandy opacities are present throughout the mesentery consistent with congestion and/or inflammation. A small amount of ascites is seen within the pelvis. Incidental note is made of a left simple renal cyst and gunshot fragments within the left paraspinal tissues. Pancreatitis is thought to result from inappropriate intrapancreatic activation of proteases, causing autodigestion of the gland and leading to pancreatic inflammatory disease. The two most common causes of acute pancreatitis are ethanol abuse and choledocholithiasis. Diagnosis of acute pancreatitis is made on the basis of the history, physical findings, and an elevation in the serum amylase. Since, however, serum amylase may be normal in 1/3 of patients having alcoholic pancreatitis, CT may be needed to confirm the diagnosis. CT findings include diffuse or focal glandular enlargement, contour irregularity, focal irregular areas of decreased attenuation secondary to necrosis or edema, and changes in the peripancreatic areolar tissues, fat, and parietal peritoneal planes. Hemorrhagic pancreatitis is an important manifestation of acute pancreatitis that may lead to hypovolemic shock and death. This may appear on CT as pancreatic and peripancreatic fluid collections with areas of high density, indicative of blood clots within the bed of the pancreas. These fluid collections may mimic pseudocysts, however, fluid collections due to hemorrhagic pancreatitis differ in that they change in size, shape, and location while pseudocysts tend to be more permanent. Typical CT findings of pseudocysts show low-density fluid masses with well-defined walls of variable thickness. Calcifications may occur within the pseudocysts. Intramural pseudocysts in the stomach, duodenum, and colon are relatively rare but do occur. These most commonly involve the posterolateral wall of the second part of the duodenum and may produce obstruction of the the bowel lumen. Features distinctive of intramural pseudocysts include extension along the wall of the duodenum, resulting in a tubular shape following the course of the duodenum, and abrupt flattening of the pseudocyst at the border of the duodenal lumen. Circumferential involvement of the duodenum may also occur.

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Peter Anderson
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