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Expanding Abdominal Mass in a 41-Year-Old Patient with a History of Alcohol Abuse

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Expanding Abdominal Mass in a 41-Year-Old Patient with a History of Alcohol Abuse CLINICAL CASE OF THE MONTH Expanding Abdominal Mass in a 41-Year-Old Patient with a History of Alcohol Abuse Racheed Ghanami, BS; Leila Obeid, MD; Betsy Buchert, BA; Scott Beech, MD; Yi-Zarn Wang, MD, DDS; and Fred A. Lopez, MD, FACP 41-year-old man with a history of significant al- minute, respiratory rate of 24 breaths per minute, and cohol use presented to an outside hospital with blood pressure of 118/56 mmHg. The patient appeared A complaints of nausea, vomiting, epigastric pain, acutely ill and lethargic. Though his speech was slurred, and subjective fever for 4 days. He also complained of he was oriented in all spheres. Physical exam further dizziness and weakness that began 1 day prior to pre- revealed temporal wasting, anicteric sclera, and dry sentation. The patient stated that he drank in excess of mucous membranes. The abdomen was not distended one case of beer the night prior to presentation. There but decreased bowel sounds were appreciated. No ten- was no history of recent trauma. In the past, he experi- derness of the abdomen was elicited with palpation, and enced sporadic episodes of abdominal pain which lasted there was no evidence of a palpable mass or hepatosple- for up to 2 days. The episodes were typically preceded by nomegaly. excessive drinking of alcohol. The patient did report a Laboratory values on admission were a white count 20-pound weight loss that occurred over the prior 2 years, of 14,000/µL (normal range, 4,500-11,000/µL), hemat- but denied chest pain, shortness of breath, post-prandial ocrit of 47.7% (normal range, 40-51%), platelets of abdominal pain, change in bowel habits, change in stool 392,000/µL (normal range, 130,000-400,000/µL), amy- color, urinary symptoms, or skin abnormalities. lase of 349 U/L (normal range, 25-115 U/L), sodium of The patient has no significant medical history and 149 mmol/L (normal range, 135-146 mmol/L), potas- was not on any prescribed medications. A construction sium of 3.5 mmol/L (normal range, 3.6-5.2 mmol/L), chlo- worker, he smoked one-half pack of cigarettes per day for ride of 83 mmol/L (normal range, 96-107 mmol/L) , bi- 24 years. He drank beer regularly, sometimes drinking carbonate of 36 mmol/L (normal range, 24-32 mmol/L) , up to one and one-half cases daily. The patient denied blood urea nitrogen of 86 mg/dL (normal range, 7-25 mg/ intravenous drug use but did admit to smoking cocaine. dL), creatinine of 6.9 mg/dL (normal range, 0.6-1.2 mg/ On presentation, the patient’s vital signs were: tem- dL), glucose of 163 mg/dL (normal range, 70-115 mg/ perature of 97° Fahrenheit, pulse rate of 129 beats per dL), calcium of 10.0 mg/dL (normal range 8.4-10.3 mg/ CME INFORMATION TARGET A UDIENCE CREDIT The July/August Clinical Case of the Month is intended The LSMS Educational and Research Foundation designates for family physicians, general internists, medicine this educational activity for a maximum of one (1) category subspecialists, general practitioners, critical care spe- 1 credit toward the AMA Physician’s Recognition Award. cialists, obstetricians-gynecologists, emergency medi- Each physician should claim only those hours of credit that cine physicians, pediatricians, dermatologists, patholo- he/she actually spent in the educational activity. gists, radiologists, general surgeons, and psychiatrists. DISCLOSURE Mr. Ghanami has nothing to disclose. EDUCATIONAL OBJECTIVES Dr. Obeid has nothing to disclose. The Clinical Case of the Month is a regular educational Ms. Buchert has nothing to disclose. feature presented by the Louisiana State University De- Dr. Beech has nothing to disclose. partment of Medicine in New Orleans. Medical students, Dr. Wang has nothing to disclose. residents, postdoctoral fellows, and faculty collaborate Dr. Lopez discloses that he is a member of the LSMS in the preparation of these discussions. After reading Journal Board and the LSMS Journal Editorial Board. this article, physicians should be able to identify and to understand better the etiology, clinical presentation, com- ORIGINAL RELEASE DATE EXPIRATION DATE plications, diagnosis, and treatment of pancreatitis. 8/1/2004 8/31/2005 Estimated time to complete this activity is 1 hour. J La State Med Soc VOL 156 July/August 2004 181 Journal of the Louisiana State Medical Society Figure 1. Noncontrast enhanced CT demonstrates pancreatic Figure 2. Coronal magnetic resonance cholangiopancrea- pseudocyst (PS). The duodenum (arrow) is compressed between tography demonstrates high signal fluid within the Pseudocyst the pseudocyst and the head of the pancreas (H) resulting in (PS) and obstructed stomach (G). The common bile duct is also proximal bowel obstruction. dilated (arrow). dL), total protein of 10.7 g/dL (normal range, 6-8 g/dL), of “fibrous tissue without epithelial lining” was consis- albumin of 5.6 g/dL (normal range 3.4-5.0 g/dL), and tent with the diagnosis of pancreatic pseudocyst. An area normal liver transaminase values. of the jejunum was then selected and transected. The A chest x-ray revealed no abnormalities. A computed distal portion was anastomosed to the pseudocyst in a tomogram (CT) of the abdomen showed a 9.1 cm x 6.0 cm side-to-side fashion over the most dependent portion of x 5.8 cm cystic mass involving the head of the pancreas. the cyst, and the proximal portion of the small bowel It was felt that this finding could represent a pancreatic was reanastomosed to the jejunum approximately 40 cm neoplasm, a pseudocyst with hemorrhagic components, distal to the cystojejunostomy site to reestablish the con- or an infectious process. Obstructive changes involving tinuity of the GI tract. The patient tolerated the proce- the duodenal folds were also noted. The abdominal ul- dure with no complications. He recovered uneventfully trasound supported the initial CT results. The patient and was discharged to home on postoperative day 6. was transferred to our institution for endoscopic retro- grade cholangiopancreatography (ERCP). DISCUSSION Upon arrival to our hospital, a second abdominal CT was performed (Figure 1). This study demonstrated a Acute pancreatitis is a common medical condition that 14 cm x 11.3 cm x 6.7 cm cystic structure involving the is often initially evaluated by the primary care physician lateral wall of the 2nd and 3rd portions of the duodenum, and usually responds to supportive care including in- which was felt to be a pseudocyst or a duodenal he- travenous fluids, bowel rest, and pain control. However, matoma. A magnetic resonance cholangiopancrea- one must not underestimate the potential life-threaten- tography (Figure 2) supported the diagnosis of pancre- ing complications of acute pancreatitis. atic pseudocyst. The patient was taken to the operating room where drainage of the cyst with a Roux-en-Y Clinical Presentation cystojejunostomy was performed. Specifically, a bilateral Typically, acute pancreatitis presents as constant epi- subcostal incision was made to enter the peritoneum. gastric and periumbilical pain, usually radiating to the The cystic mass was identified and the lesser sac was back but sometimes to the chest, lower abdomen, and then entered in order to inspect the pancreas and reveal flank.1 It is often associated with nausea and vomiting. the anatomic relationship between the mass and the pan- The pain is worse in the recumbent position and is re- creas. Dark red fluid consistent with old blood was next lieved by sitting up. Low grade fever, tachycardia, and aspirated from the cyst and sent to the lab to confirm the hypotension are not uncommon. On physical exam, de- pre-operative radiographic diagnosis. An elevated fluid creased bowel sounds and abdominal distention due to amylase level further supported the diagnosis of a com- intestinal hypomotility are common findings. Epigastric municating pancreatic pseudocyst. Furthermore, a pre- pain is usually elicited with palpation and it is impor- sumed cyst-content-induced arterial erosion event in the tant to look for signs of severe necrotizing pancreatitis immediate preoperative period was supported by the such as Cullen’s sign (i.e., periumbilical discoloration history of a rapid preoperative expansion of the mass indicating hemoperitoneum) and Grey-Turner sign (i.e., resulting in gastric outlet obstruction. A portion of the green-brown or red-purple flank discoloration represent- cyst wall was sent for frozen section to rule out cystic ing tissue breakdown of hemoglobin).1 Laboratory data neoplasm of the pancreas. The histopathologic finding typically reveals an elevated serum amylase and lipase, 182 J La State Med Soc VOL 156 July/August 2004 increased or normal white blood cell count, and a serum obtained in suspected severe pancreatitis or when pan- calcium level that can be elevated, decreased, or normal. creatitis-associated signs or symptoms that fail to resolve. Hypertriglyceridemia and hyperglycemia may also be A commonly utilized CT grading system is Balthazar’s present, and transient elevation(s) of serum bilirubin, acute pancreatitis CT Severity Index (CTSI).4 Grade A is alkaline phosphatase, and aspartate aminotransferase given for a normal pancreas, Grade B for pancreatic en- are often reported. Plain abdominal x-rays are usually largement, Grade C for peripancreatic inflammation, non-specific, though they may reveal an ileus pattern, Grade D for a single ill-defined peripancreatic fluid col- i.e., the sentinel loop. lection, and Grade E for more than two peripancreatic collections, including gas in and around the pancreas. Causes Grades D and E are associated with greater risks for in- The two most common causes of acute pancreatitis are fection and mortality. CTSI takes into account the grade gallstones and alcohol abuse,1 together accounting for and the degree of necrosis noted on CT scan.
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