Pseudopancreatic cyst

A 50 year old female presented to the Surgery OPD with a an upper abdominal swelling for the past 18 months. Her history revealed that she had developed a dull-aching, continuous epigastric pain 18 months ago, which was not aggravated to relieved by meals. She, however, vomited a greenish fluid after every meal. The vomitus did not contain old food particles, and was not foul smelling. She also developed steatorrhoea 2 days after vomiting began. These symptoms gradually regressed, and she noticed an epigastric lump gradually developing, which increased to the present size in 6 months, and has remained static for the past 1 year. The lump is associated with slight dull-aching pain. The patient was lost her appetite, and and has continuously been losing weight for the past 18 months.
She does not report of any blood in vomitus, melaena, or jaundice. Her bladder and bowel habits are normal at present. Her appetite is diminished. She sleeps normally at night.
A past history reveals jaundice 5 years ago. There is no history of any other major illness, prolonged drug intake, or hospitalization. She is not known to have tuberculosis, diabetes or hypertension. She never took OCPs. She has no known drug allergies.
She is not addicted to alcohol, and denies any other addictions.
She has two children, born by normal vaginal delivery at home. One child was aborted 10 years ago due to trauma to the abdomen.

Her general examination reveals poor nutrition and moderate pallor, but is otherwise normal.

A local abdominal examination reveals a solitary, tense cystic lump, globular in shape, measuring 23 cm x 19 cm lying retro-peritoneally in the epigastrium, extending to the left hypochondrial, left iliac and the umbilical regions. It has a smooth surface and well defined margins, apart from the upper margin which disappears under the costal margin. It shows a positive fluid thrill. It moves slightly with respiration. It is not compressible or reducible, shows cough impulse or pulsations.
Umbilicus is shifted downwards and to the left. The abdomen shows stria gravidarum, and venous prominence in the flanks.
Deep tender points show no abnomality. Hernial orifices appear normal. PR and PV examinations were not done.

Provisional diagnosis: Pseudo-pancreatic cyst in a 50 year old female.

DIfferential diagnoses:

1. Pancreas: Cystadenoma/Cystadenocarcinoma
   
2. Hydatid cyst of pancreas
3. Spleen: Hydatid cyst
4. Liver: Hydatid cyst
5. Simple cyst of liver
6. Mesenteric cyst

Investigations to be done:
USG upper abdomen: I will expect a cystic swelling in relation to the pancreas.
Serum amylase & lipase: I will expect elevated values.
General Pre-anaesthetic checkup

Definitive treatment:
Drainage of the cyst. Most commonly, internal drainage is done, by making a communication of the cyst with the gut, i.e. stomach, duodenum or jejunum.

Complications of pseudopancreatic cyst:

1. Infection
2. Hemorrhage
3. Rupture of the Cyst
   
4. Gastric Outlet Obstruction
5. Obstructive jaundice