Some Migratory Aspects of Inflammatory Collections of Pancreatic Origin

Abstract

In recent years roentgenologists have become increasingly aware of the continuing, chronic, relapsing, and progressive nature of pancreatitis, as well as its varied manifestations. Its presence may be difficult to detect, or even suspect, since the clinical picture and history may vary from patient to patient and even in the same patient at different times. Accordingly, possibly because of some enzymatic activity of the inflammatory collection, more likely because of the favorable action of various anti-inflammatory agents attenuating the disease, and also because of better methods of roentgen diagnosis, we have in the past ten years observed more than 30 patients in whom inflammatory collections of pancreatic origin migrated to various regions in the abdomen or thorax. In many instances, these inflammatory collections presented at a distance as the initial phase of the disease, masquerading as a local abscess, a perinephritic abscess, a subphrenic abscess, a fistula, a pleurisy, an empyema, a mediastinal mass, an appendicitis or a perityphlitis, an abscess in the left iliac fossa, a collection in the lesser sac, and a true cyst. When the inflammation extends beyond the confines of the pancreas, there may be visualized localized space-occupying lesions labeled inflammatory tumefactions or collections. These may become located in the retroperitoneal area behind the pancreas, in the lesser omentum between the stomach and liver, in the lesser peritoneal sac, in the gastrocolic ligament between the stomach and the transverse colon, or high up under each half of the diaphragm. On the right side the collection may remain in situ between the liver and the diaphragm or perforate into the right pleural cavity, producing an empyema. Left subphrenic collections may also remain in situ or break through the diaphragm, forming mediastinal, pericardial, or pleural collections. In one such instance, there was lysis of the diaphragm and the esophagus deviated towards the left. In another, the inflammatory material lysed the diaphragm in the region of the esophageal orifice and drained upward into the mediastinum posteriorly as far as the level of D-4, forming a large pseudocyst which could be demonstrated by postoperative pancreatography. The inflammatory material may drain downward retroperitoneally to the right lower quadrant, producing a perityphlitis. On the left side the material may collect just beyond the pancreatic tail in the region of the hilus of the spleen or track down the left gutter retroperitoneally for variable distances as far as the left iliac fossa, often assuming a cyst-like shape. These collections usually communicate with the pancreas by fistulous tracts which can be filled during operative or postoperative pancreatography. A fistulous tract may open through the abdominal wall to the overlying skin, either spontaneously, after surgery, or as a result of penetrating or other wounds. General Abdominal Roentgen Manifestations: