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Extrahepatic pseudocyst in an adult

Yi-An Chen, Cheng-Ta Hsieh and Jui-Ming Sun
Neurosciences Journal January 2021, 26 (1) 97-102; DOI: https://doi.org/10.17712/nsj.2021.1.20200117

Article Figures & Data

Figures

  • Figure 1
    Figure 1

    Axial view of computed tomographic scan of brain revealed brain atrophy, large encephalomalacia at left basal ganglion, and mild hydrocephalus.

  • Figure 2
    Figure 2

    Abdominal X-ray shows the peritoneal tip of the shunt in the right upper quadrant of the abdomen with a tube loop (white arrow).

  • Figure 3
    Figure 3

    Enhanced computed tomographic scan of the abdomen. (A) Axial view shows the subcutaneous cyst (white arrow) at the abdominal entry site of the shunt. (B) Axial view shows the peritoneal tube penetrating the extrahepatic pseudocyst (white asterisk). (C) Reconstructed coronal view shows the shunt tip (white arrow) penetrating the extrahepatic pseudocyst (white asterisk).

  • Figure 4
    Figure 4

    Intraoperative laparoscopic view reveals the unroofing of the pseudocyst.

  • Figure 5
    Figure 5

    The microscopic view of this cystic lesion demonstrates a dense thick fibrous wall and chronic granulomatous inflammation

  • Figure 6
    Figure 6

    The treatment algorithm for ventriculoperitoneal (VP) shunt-associated hepatic pseudocyst. For shunt, the distal externalization or repositioning distal catheter is initially suggested. For pseudocyst, the treatments include (1) percutaneous drainage, (2) cyst resection, (3) cyst fenestration, (4) exploratory laparotomy, (5) laparoscopic approach, or (6) observation. When the cerebral spinal fluid is sterile and hydrocephalus still exists, the revision of shunt, VA (ventriculoatrial) shunt, or lumboperitoneal (LP) shunt can be performed. Shunt may be removed when no hydrocephalus develops.

Tables

  • Table 1

    The timeline for the presented case.

    DateRelevant Past Medical History and Interventions
    He had a 4-year history of spontaneous intracerebral hemorrhage at the left basal ganglion with ventricular extension and underwent VP shunt surgery with medium pressure reservoir implantation (Medtronic, USA) because of posthemorrhagic hydrocephalus
    DateSummaries from Initial and Follow-up VisitsDiagnostic Testing (including dates)Interventions
    2020/5/11• A progressive bulging mass around the previous surgical site at the right upper quadrant of the abdomen 2 weeks before admission• Laboratory examination showed white blood cell count of 5570/µL and a C-reactive protein level of 0.34 mg/µL. (2020/5/11)• Distal externalization of the VP shunt (2020/5/12)
    • Laparoscopic unroofing of the cystic lesion (2020/5/14)
    • Abdominal radiography showed a loop of the peritoneal tube around the right upper quadrant of the abdomen. (2020/5/11)• The distal shunt was ligated at the right anterior chest region (2020/5/22)
    • Computed tomography (CT) scan of the abdomen showed a large cystic lesion at the right extrahepatic region was also discovered, containing the peritoneal tube of the VP shunt. (2020/5/12)• Flomoxef 1gm i.v. q8h (2020/5/12 to 2020/5/22)
    • CSF culture: no bacterial growth (2020/5/12 to 2020/5/14)
    2020/5/23Discharge without symptoms of hydrocephalus or fever
    2020/7/28Alert and orientated. No recurrent symptoms.
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