It 1 V

Fig. 11—23. Spontaneous rupture of pancreatic pseudocyst into colon.

Barium enema study demonstrates communication at anatomic splenic flexure into pseudocyst cavity of tail of pancreas.

Fig. 11—24. Spontaneous drainage of pancreatic pseudocyst into colon.

Barium enema study reveals that a fistulous communication has been established between the region of the anatomic splenic flexure and an irregular pseudocyst extending retroperitoneally from the tail of the pancreas.

Dissecting Pseudocyst Pancreatic Pseudocyst Fistula

Fig. 11—25. Spontaneous fistula formation from infected pancreatic pseudocyst to colon.

(a) Pancreatic abscess with extraluminal gas loculation displaces splenic flexure of colon. A small amount of contrast material has extravasated into the abscess (arrow).

(b) Fistulogram performed after drainage of abscess demonstrates the irregular cavity (C) with the tract (arrows) extending to the colon.

(Courtesy of J.L. Clements, Jr., M.D., Emory University School of Medicine, Atlanta, GA.)

Proximal Diverting Procedure

b is frequent. The recommended operative procedure is proximal diverting colostomy and debridement with external drainage of the peripancreatic collection.22

Extraperitoneal dissection inferiorly may result in pseudocyst formation within the anterior pararenal space (Figs. 11-26 through 11-29), with effects on the long limbs of the colon, sigmoid colon, and rectum, and rarely may progress as far as the groin.26-30 Fat necrosis at this site may mimic many other disease processes. The patient illustrated in Figure 11-30 presented with an acute abdomen and an inflamed scrotum that drained "beef-broth" material with a high amylase content secondary to fat necrosis. The barium enema study indicates the pathway of the pancreatic enzymes into the phrenicocolic ligament and inferiorly beyond the sig-moid colon to the inguinal region.

Picture Soft Tissure Colon

Fig. 11—27. Extension of pancreatitis into the pelvis.

Effects on the anatomic splenic flexure (arrows) from extravasated enzymes are shown. A large pseudocystic soft-tissue mass extends inferiorly through the left anterior pararenal space to the pelvis, resulting in displacement and mucosal inflammatory changes of the descending colon.

Fig. 11—26. Acute pancreatitis extending to descending colon.

Beginning at the level of the anatomic splenic flexure and extending downward, the descending colon shows spasm, limited distensibility, and edematous changes that are more marked on the medial wall. These changes reflect the inferior extension of the pancreatic inflammatory process through the anterior pararenal space. Extraluminal gas stippling is due to early abscess formation.

Fig. 11—28. Extension of pancreatitis into the pelvis.

Massive pancreatitic exudate dissecting along the left retroperitoneum into the pelvis results in extensive edema of the sigmoid colon with mass effect and displacement of the rectum to the right. (Reproduced from Farman et al.26)

Fig. 11—28. Extension of pancreatitis into the pelvis.

Massive pancreatitic exudate dissecting along the left retroperitoneum into the pelvis results in extensive edema of the sigmoid colon with mass effect and displacement of the rectum to the right. (Reproduced from Farman et al.26)

Fig. 11—29. Extension of pancreatitis into the pelvis.

A pseudocyst of the pancreas extends retroperitoneally to the pelvis with extrinsic compression and partial obstruction of the distal sigmoid colon.

Fig. 11—30. Extension of acute pancreatitis into scrotum.

Pseudocyst formation in the tail of the pancreas depresses the distal transverse colon. In addition, extravasated enzymes within the phrenicocolic ligament result in localized narrowing of the anatomic splenic flexure (top arrow). Inferior extension extraperitoneally on the left is revealed by compression of the sigmoid colon (bottom arrow).

(Courtesy of Jack Farman, M.D., Columbia-Presbyterian Medical Center, New York, NY.)

Sigmoid Colon Compression

Effects of Pancreatitis on the Duodenum, Small Bowel, and Cecum: Spread Along Small Bowel Mesentery

The inflammatory process associated with extravasated pancreatic enzymes may disseminate along the root of the small bowel mesentery, either for a portion or for its entire length. Figure 11-31 demonstrates these anatomic relationships near the beginning of the mesentery. Spread through the leaves brings the process to intestinal vessels and to an individual or multiple loops (Fig. 1132). Figure 11-33 documents communication of the

Mesenteric Root And Leaves

Fig. 11—31. Anatomic cross-section immediately below the pancreas shows the relationships of the superior mesenteric artery (SMA) and vein (SMV), in the root of the mesentery, to the third portion of the duodenum (IIID) as it continues into the fourth duodenum (IV D). Intestinal arteries (IA) course in the mesentery to loops of jejunum (JL). AO = aorta; K = kidney; IVC = inferior vena cava; TC = transverse colon.

Fig. 11—31. Anatomic cross-section immediately below the pancreas shows the relationships of the superior mesenteric artery (SMA) and vein (SMV), in the root of the mesentery, to the third portion of the duodenum (IIID) as it continues into the fourth duodenum (IV D). Intestinal arteries (IA) course in the mesentery to loops of jejunum (JL). AO = aorta; K = kidney; IVC = inferior vena cava; TC = transverse colon.

pancreas with the length of the mesenteric root. This pathway provides a plane of spread to the right lower quadrant (Fig. 11-34).

Essentials of Human Physiology

Essentials of Human Physiology

This ebook provides an introductory explanation of the workings of the human body, with an effort to draw connections between the body systems and explain their interdependencies. A framework for the book is homeostasis and how the body maintains balance within each system. This is intended as a first introduction to physiology for a college-level course.

Get My Free Ebook


Post a comment