Transverse colon displacement

Introduction Pancreatic cysts include true cysts, pseudocysts, and cystic tumors. True cysts include congenital simple cysts, polycystic disease, dermoid cysts, and retention cysts. The inner wall of the cyst is covered with epithelium. Cystic tumors include cystic adenomas and cystic carcinomas. The wall of the pseudocyst is composed of fibrous tissue and is not covered with epithelial tissue. Clinically, pancreatic cysts are most common with pseudocysts. X-ray barium meal examination also has a localization value for pancreatic pseudocysts. In addition to excluding the lesions in the gastrointestinal cavity, the signs of compression and displacement of the cysts on the surrounding organs can be seen. If there is a large pseudocyst in the stomach, the tincture can show that the stomach is moving forward, and the stomach can be compressed. A pseudocyst in the head of the pancreas can widen the duodenal curvature and shift the transverse colon upward or downward.

Cause

Pancreatic pseudocysts are cysts formed by the overflow of blood and pancreatic juice into the peripancreatic tissue, or in rare cases, into the small omental sac. The difference between a pseudocyst and a true cyst is that the latter occurs in the pancreatic tissue, the cyst is in the pancreas, and the inner layer of the capsule is composed of ductal or acinar epithelial cells; while the former is formed by the formation of a cyst wall around the pancreas. Cysts, there are no epithelial cells in the wall of the capsule, so it is called a pseudocyst.

About 75% of cases of pseudocysts are caused by acute pancreatitis, about 20% of cases occur after pancreatic trauma, and 5% of cases are caused by pancreatic cancer. A group reported 32 cases of pseudocysts, of which 20 cases occurred after acute pancreatitis, 3 cases occurred after abdominal trauma, 8 cases had no clear cause, and 1 case was formed after compression of pancreatic fibrosarcoma. In 20 cases after acute pancreatitis, cysts were first developed one week after onset, and at the latest 2 years after onset, most of them were between 3 and 4 weeks after onset.

Pancreatic juice containing a variety of digestive enzymes exudes from the necrotic pancreatic tissue to the peritoneal space around the pancreas, causing an inflammatory reaction and cellulose deposition. After one week to several weeks, a fibrous envelope is formed, and the posterior peritoneum constitutes the anterior wall of the cyst. Or the pancreatic juice directly infiltrates into the small omental sac, Winslow pores are often closed due to inflammation, and cysts are formed in the small omentum. Sometimes pancreatic juice enters other parts along the interstitial space to form cysts in specific parts, such as pseudo-pancreatic cysts in the mediastinum, spleen, kidney and groin.

Howard and Jorden classify pancreatic cysts according to the etiology of cyst formation: 1 pseudocyst after inflammation: seen in acute pancreatitis and chronic pancreatitis. 2 pseudo-cysts after trauma: seen in blunt trauma, penetrating trauma or surgical trauma. 3 tumor-induced pseudocyst. 4 parasitic pseudocyst: caused by aphids or cysticercosis. 5 idiopathic or unexplained.

Pancreatic inflammation, trauma, etc. cause pancreatic necrosis, pancreatic juice and blood to accumulate around the pancreas, the omentum and stomach, and the small omentum, which can stimulate the surrounding tissue and make the connective tissue proliferate. If no pus infection, it can form a Fibrous wall. Animal experiments have shown that the formation of a pseudocyst wall takes 4 weeks and takes at least 6 weeks in the human body. A typical pseudocyst is in communication with the main pancreatic duct. This pancreatic cyst can continue to expand and continue to exist due to the secretion pressure of the pancreatic juice in the capsule.

About 80% of pseudo-pancreatic cysts are single-shot in size, generally 15cm in diameter and less than 3cm in size. The larger ones have reported a capacity of 5000ml. The liquid in the capsule is alkaline, with protein, mucus, cholesterol and red blood cells. Its color is not the same, it can be clarified yellow liquid, but also can be a chocolate-like turbid liquid. Although the amylase content is increased, generally no activated enzyme exists.

The wall of the pseudocyst can be adhered due to the inflammatory reaction; the surface often has necrotic tissue attached; due to the formation of granulation tissue, the wall of the capsule is continuously thickened. Cysts can develop in all directions during their expansion. If activated pancreatic enzyme enters the sac and invades the blood vessels on the wall of the capsule, it can cause intracapsular hemorrhage. Becker reported that when the cyst was infected, the fatal cyst ruptured due to pancreatic enzyme invasion into the blood vessels and the wall of the capsule, and the bleeding was 70% to 90%. Pseudocysts, especially pancreatic head cysts, can erode the digestive tract to form internal hemorrhoids. Intraperitoneal cysts invading the splenic artery can cause intra-abdominal hemorrhage. Large pseudocysts can compress adjacent organs and cause oppressive symptoms.

It is generally believed that pancreatic pseudocysts are more common in the pancreas and tail, but in recent years, due to the widespread use of B-mode ultrasound imaging, the discovery rate of pancreatic pseudocysts has increased significantly. Sugawa and Walt report that 50% of the pseudocysts are located in the head of the pancreas.

When the pancreas is inflamed or (and) the pancreatic duct is damaged, the pancreatic juice and effusion can spread along the posterior peritoneal space to form an ectopic pseudocyst. For example, the mediastinal cyst can be formed through the transverse medial septum to form the mediastinal cyst or even form the neck. Cysts; downwards can form groin or genital cysts along the left and right lumbar space.

an examination

Related inspection

Urine amylase serum amylase (AMS) gastrointestinal disease ultrasound examination colonography upper gastrointestinal X-ray barium meal

In patients with acute pancreatitis or pancreatic trauma, persistent upper abdominal pain, nausea and vomiting, weight loss and fever, abdominal fistula and cystic mass should first consider the possibility of pseudo-pancreatic cyst formation. Perform the following checks in a timely manner to make a diagnosis.

(a) Determination of blood urease amylase

The pancreatic enzyme in the cyst can be found in hematuria after absorption through the cyst wall, causing a mild to moderate increase in amylase in serum and urine. However, it has been reported that amylase may not increase in about 50% of cases. Generally in the pseudocyst caused by acute pancreatitis, serum amylase often continues to rise, and chronic pancreatitis is often normal.

(2) B-ultrasound inspection

B-ultrasound is a simple and effective method for diagnosing pancreatic pseudocyst. In the upper abdomen, a liquid dark area with a clear position and a certain range can be detected. B-ultrasound is particularly helpful in identifying masses and cysts, and the correct rate of diagnosis of pancreatic pseudocysts can reach 73% to 91%. Dynamic ultrasound exploration can be used to understand changes in cyst size. In addition, under the guidance of B-ultrasound, it can be used as a capsule puncture, and the cyst fluid is taken for biochemical and cytological examination.

(three) CT examination

On the CT scan, the pancreatic pseudocyst was a smooth circular or oval density uniform reduction zone. If the CT examination shows a gas-liquid level, it indicates the formation of an infectious abscess. (4) X-ray examination X-ray barium meal examination also has a localization value for pancreatic pseudocyst. In addition to excluding the lesions in the gastrointestinal cavity, the signs of compression and displacement of the cyst to the surrounding organs are still visible. If there is a large pseudocyst in the stomach, the tincture can show that the stomach is moving forward, and the stomach can be compressed. A pseudocyst in the head of the pancreas can widen the duodenal curvature and shift the transverse colon upward or downward. A pancreatic calcification shadow can be found on the abdomen.

(5) ERCP

The presence and location of cysts can be determined by ERCP and help to differentiate from pancreatic cancer. In the pseudocyst, the ERCP showed cyst filling; the main pancreatic duct obstruction, the obstruction end was conical or discontinuous; the common bile duct was displaced; in the non-communicating cyst, the pancreatic duct was compressed and the localized branch was not filled. However, about half of the pseudocysts do not communicate with the main pancreatic duct, so normal pancreatic duct angiography cannot be denied. The ERCP can also check for the presence of a fistula. However, ERCP can promote secondary infection or spread inflammation, so cases that have been confirmed in the diagnosis should not be classified as routine examinations.

(6) Selective angiography

Selective angiography has a positive diagnostic value for pseudocysts and can show lesions. The cyst area is avascular area and sees displacement of adjacent vessels. This test can correctly diagnose the vascular invasion, determine whether there is bleeding and the source of bleeding, and determine whether there is a pseudoaneurysm in the wall. Angiography is more valuable than B-ultrasound and CT in judging whether a pseudocyst invades the spleen.

A few pseudocysts are asymptomatic and are only found during B-ultrasound examinations. In most cases, the clinical symptoms are caused by cysts pressing adjacent organs and tissues. About 80% to 90% of abdominal pain occurs. Most of the pain is in the upper abdomen, and the range of pain is related to the location of the cyst, often radiating to the back. Pain occurs due to cyst compression of the gastrointestinal tract, posterior peritoneum, celiac plexus, and inflammation of the cyst and the pancreas itself. There are about 20% to 75% of people with nausea and vomiting, and about 10% to 40% of those with decreased appetite. Weight loss is seen in about 20% to 65% of cases. Heat is often low fever. Diarrhea and jaundice are rare. Cysts can cause pyloric obstruction if compression of the pylorus; compression of the duodenum can cause duodenal stagnation and high intestinal obstruction; compression of the common bile duct can cause obstructive jaundice; compression of the inferior vena cava caused by symptoms of inferior vena cava obstruction and lower extremity edema; oppression The ureter can cause hydronephrosis and the like. In the mediastinal pancreatic pseudocyst, there may be symptoms of heart, lung and esophageal compression, chest pain, back pain, difficulty swallowing, and jugular vein engorgement. If the pseudocyst extends to the left groin, scrotum or rectal uterine crypt, symptoms of rectal and uterine compression may occur.

At the time of physical examination, about 50% to 90% of patients have a mass in the upper abdomen or the left quarter. The mass is spherical, the surface is smooth, and there is no sense of nodule, but it can be fluctuating, the mobility is not large, and there is often tenderness.

Differential diagnosis

Differential diagnosis of transverse colon displacement:

1. Pancreatic cancer: with abdominal pain, poor appetite, weight loss, jaundice, etc. as the main performance, the condition is serious, rapid deterioration, gastrointestinal barium meal, CT, B-ultrasound and other tests help to identify.

2. Stomach and ulcer: recurrent episodes of stomach cramps, closely related to diet, periodicity, rhythm, X-ray barium meal examination found sputum, fibrous gastroscopy can be seen ulcer lesions.

3. spleen: mainly refers to malabsorption, the disease is mostly in the small intestine, and can be similar to the performance of painless pancreas, but the spleen has obvious symptoms of qi stagnation, such as anemia, total plasma protein and Low cholesterol, D-xylose absorption test was significantly reduced, glucose tolerance test showed a low-flat curve, no increase in blood glucose, urine glucose negative, etc. can be identified.

4. Renal cysts: renal cysts (cyst of kidney) are a general term for cystic masses of varying sizes in the kidney that are not connected to the outside world. Common renal cysts can be divided into adult polycystic kidney disease and simple kidney. Cysts and acquired renal cysts.

5. Hepatic cyst: hepatic cyst, cyst of liver, popular point is the "bubble" in the liver. The vast majority of hepatic cysts are congenital, that is, due to certain abnormalities in congenital development leading to the formation of hepatic cysts. There are few factors of acquired nature. For example, in pastoral areas, if people are infected with cysticercosis, parasitic cysts will be produced in the liver. Trauma, inflammation, and even tumors can also cause liver cysts. Cysts can be single-shot, only one, as small as 0.2 cm; can also be as many as ten, dozens, or even one can be as large as several tens of centimeters. Patients with multiple hepatic cysts sometimes have cysts of other internal organs, such as renal cysts, pulmonary cysts, and occasional pancreatic cysts, spleen cysts.

In patients with acute pancreatitis or pancreatic trauma, persistent upper abdominal pain, nausea and vomiting, weight loss and fever, abdominal fistula and cystic mass should first consider the possibility of pseudo-pancreatic cyst formation. Perform the following checks in a timely manner to make a diagnosis.

(a) Determination of blood urease amylase

The pancreatic enzyme in the cyst can be found in hematuria after absorption through the cyst wall, causing a mild to moderate increase in amylase in serum and urine. However, it has been reported that amylase may not increase in about 50% of cases. Generally in the pseudocyst caused by acute pancreatitis, serum amylase often continues to rise, and chronic pancreatitis is often normal.

(2) B-ultrasound inspection

B-ultrasound is a simple and effective method for diagnosing pancreatic pseudocyst. In the upper abdomen, a liquid dark area with a clear position and a certain range can be detected. B-ultrasound is particularly helpful in identifying masses and cysts, and the correct rate of diagnosis of pancreatic pseudocysts can reach 73% to 91%. Dynamic ultrasound exploration can be used to understand changes in cyst size. In addition, under the guidance of B-ultrasound, it can be used as a capsule puncture, and the cyst fluid is taken for biochemical and cytological examination.

(three) CT examination

On the CT scan, the pancreatic pseudocyst was a smooth circular or oval density uniform reduction zone. If the CT examination shows a gas-liquid level, it indicates the formation of an infectious abscess.

(4) X-ray examination

X-ray barium meal examination also has a localization value for pancreatic pseudocysts. In addition to excluding the lesions in the gastrointestinal cavity, the signs of compression and displacement of the cysts on the surrounding organs can be seen. If there is a large pseudocyst in the stomach, the tincture can show that the stomach is moving forward, and the stomach can be compressed. A pseudocyst in the head of the pancreas can widen the duodenal curvature and shift the transverse colon upward or downward. A pancreatic calcification shadow can be found on the abdomen.

(5) ERCP

The presence and location of cysts can be determined by ERCP and help to differentiate from pancreatic cancer. In the pseudocyst, the ERCP showed cyst filling; the main pancreatic duct obstruction, the obstruction end was conical or discontinuous; the common bile duct was displaced; in the non-communicating cyst, the pancreatic duct was compressed and the localized branch was not filled. However, about half of the pseudocysts do not communicate with the main pancreatic duct, so normal pancreatic duct angiography cannot be denied. The ERCP can also check for the presence of a fistula. However, ERCP can promote secondary infection or spread inflammation, so cases that have been confirmed in the diagnosis should not be classified as routine examinations.

(6) Selective angiography

Selective angiography has a positive diagnostic value for pseudocysts and can show lesions. The cyst area is avascular area and sees displacement of adjacent vessels. This test can correctly diagnose the vascular invasion, determine whether there is bleeding and the source of bleeding, and determine whether there is a pseudoaneurysm in the wall. Angiography is more valuable than B-ultrasound and CT in judging whether a pseudocyst invades the spleen.

A few pseudocysts are asymptomatic and are only found during B-ultrasound examinations. In most cases, the clinical symptoms are caused by cysts pressing adjacent organs and tissues. About 80% to 90% of abdominal pain occurs. Most of the pain is in the upper abdomen, and the range of pain is related to the location of the cyst, often radiating to the back. Pain occurs due to cyst compression of the gastrointestinal tract, posterior peritoneum, celiac plexus, and inflammation of the cyst and the pancreas itself. There are about 20% to 75% of people with nausea and vomiting, and about 10% to 40% of those with decreased appetite. Weight loss is seen in about 20% to 65% of cases. Heat is often low fever. Diarrhea and jaundice are rare. Cysts can cause pyloric obstruction if compression of the pylorus; compression of the duodenum can cause duodenal stagnation and high intestinal obstruction; compression of the common bile duct can cause obstructive jaundice; compression of the inferior vena cava caused by symptoms of inferior vena cava obstruction and lower extremity edema; oppression The ureter can cause hydronephrosis and the like. In the mediastinal pancreatic pseudocyst, there may be symptoms of heart, lung and esophageal compression, chest pain, back pain, difficulty swallowing, and jugular vein engorgement. If the pseudocyst extends to the left groin, scrotum or rectal uterine crypt, symptoms of rectal and uterine compression may occur.

At the time of physical examination, about 50% to 90% of patients have a mass in the upper abdomen or the left quarter. The mass is spherical, the surface is smooth, and there is no sense of nodule, but it can be fluctuating, the mobility is not large, and there is often tenderness.

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