Answer
1) Epigastric mass
- Left lobe hepatomegally (carcinoma, abscess**most commonly right lobe, infection)
- Pancreas (carcinoma, pseudocyst)
- Vascular (Abdominal Aorta Aneurysm)
- Stomach (gastric ca ** usually not enlarged until late stage. Common presentation is early satiety)
- Transverse colon (carcinoma ** commonly present as obstructive symptoms rather than mass, intussuception)
- Subphrenic abscess
2) History to take
- Constitutional symptoms to suggest carcinoma
- Exclude gastric carcinoma (indigestion, peptic ulcer disease, gastric outlet obstruction symptoms, malena, hematemesis)
- Transverse colon ca (Obstruction, PR bleed, anemic symptom, altered bowel habit)
- Pancreatic pseudocyst (persistent abdominal pain, anorexia, abdominal mass, trauma, acute & chronic pancreatitis)
- Liver abscess (abdominal pain at liver area, jaundice, fever, poor sanitation, history of dysentry)
- Ca of pancreas (significant weight loss, mid epigastric pain, diabetes mellitus, painless obstructive jaundice ** ca head of pancreas, depression, migratory thrombophlebitis, venous thrombosis)
- Impending AAA rupture (sudden, severe and constant low back, flank, abdomen or groin pain, syncope, sign and symptom of shock, smoking, COPD, hypertension, patient feel something pulsatile from the abdomen)
- Subphrenic abscess (abdominal pain, fever with chills and rigor, loss of appetite)
3) CT scan shows area of hypodense arising from the pancreas which is well democrated margin, wall appear hyperdense than the central part, smooth outline and extending up to the stomach.
4) Pancreatic pseudocyst
5) Investigation (order based most likely differential diagnosis and the order of investigation is also directed by history and physical examination)
a) Blood (FBC, LFT, RFT, PT/aPTT, Serum amylase/ lipase)
b) Imaging (Abdominal X Ray, Barium meal, OGDS, ERCP, Ultrasound of the hepatobiliary system, Positron emission tomography scanning, CT angiography)
c) Tumor marker (carbohydrate antigen 19-9, Carcinoembryonic antigen)
6) Management of pancreatic pseudocyst
Management is conservative and re assurance to the patient. Most of the time, pseudocyst will regress within 6 weeks. Review back the patient. If the swelling does not regress in size or if size more than 6 cm, therefore drainage of the cyst is indicated.
Drainage is either via INTERNAL DRAINAGE or ENDOSCOPIC approach only even though previously being mentioned that percutaneous drainage is one of the option. The cyst may then join to the stomach (cystogastrostomy) for the pancreatic enzyme to be secreted (avoid leakage).
Percutaneous drainage has high complication rate especially FISTULA formation and INFECTION. Apart from it, it has high failure and recurrence rate. Furthermore,there is also high mortality rate for in-patient.