A 74 y.o. male presents with chronic abdominal pain

What does the CT show?

Our patient had a cystogastrotomy-a stent between a pancreatic cyst and the stomach for drainage.

anatomy of the pancreas ; the tail is toward the spleen

Pancreatic cysts are found in 15% of abdominal CT scans. They can either be pseudocysts which are often formed after a bout of pancreatitis from digestive enzymes leaking out,  or true cysts which include cystic neoplasms.  Although most pancreatic cysts are benign, it is important to find the ones which are malignant because surgical removal is the only cure.

PSEUDOCYSTS- are caused by inflammation in the pancreas causied by digestive enzymes leaking out. By definition they must be present for four weeks and have a developed thin wall without necrosis. Gallstones and alcoholism are the two most common causes of pseudocysts, although only less than 3% of heavy alcohol users develop pancreatic disease. Pseudocysts do not require drainage, regardless of size, unless they cause symptoms. Aspirating a pseudocyst can show an elevated amylase.

Ascaris worms can cause pancreatitis by blocking the pancreatic duct.

CYSTIC CARCINOMAS

Mucinous

IPMN – Intraductal pancreatic mucinous neoplasms-  if found in the main pancreatic duct are highly likely to be malignant.They are worrisome when more than 3 cm or  cause a dilated pancreatic duct of 5-9 mm. Aspirating a mucinous cyst can show elevated CEA.

Mucinous cystic neoplasms- are seen almost exclusively in women. They occur in the body and tail of the pancreas and have a higher potential for malignant transformation than IPMNs.  The only treatment is resection.

Non mucinous

Serous cystic tumors- have a low risk of malignant transformation

Solid non mucinous tumors have a high risk of malignant transformation

many drugs also cause pancreatitis including furosemide, simvastatin and thiazides. IgG 4 disease is a relatively new cause of autoimmune pancreatitis. Infectious causes also occur as in mumps, herpes, and HIV.

Chavan R, Ramchandani M, Nabi Z, et al. Panncreatic duct ascariasis causing recurrent pancreatitis. Endoscopy 2018;50:E292-293. https://eref.thieme.deje-videos.

Nassour I, Choti M. Types of pancreatic cysts . JAMA 2016;316(11):1226. Doi:10.001/jama.2016.9035Ohkura Y, Sasaki K, Matsuda M, et al. BMC Med Imaging 2015;15:14.

Ohkura Y, Sasaki K, Matsuda M, et al. BMC Med Imaging 2015;15:14.

Zippi M, Fina P, Hong W, et al. Recurrent epigastric pain: Pancreatic von Hippel-Lindau. This disease is caused by a gene on chromosome 3 and results in benign cysts in many organs which have the potential for malignant transformation.

extra credit: what disease is genetic and associated with cysts of multiple organs including the pancreas?

ans: Von Hippel Lindau