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Gastrointestinal: Recurrent acute pancreatitis with a large fluid collection: Pseudocyst or else?

An 18-year-old boy presented with history of pain in the right hypochondrium and right lumbar region for 9 days. He also gives history of several episodes of abdominal pain over the last 2 years and was diagnosed with idiopathic recurrent acute pancreatitis based on raised serum amylase/lipase, characteristic pain, and findings suggestive of pancreatitis on imaging. In the present episode, he does not give any history of fever or vomiting besides pain. Physical examination revealed an ill-defined lump occupying the entire right quadrant of the abdomen. Blood evaluation including hemogram and serum amylase/lipase levels were within normal limits. Contrast-enhanced computed tomography (CECT) of the abdomen was performed, which displayed one large fluid collection in the head region of the pancreas and two small fluid collections near the tail (Fig. 1a,b). Other findings on CECT included a prominent pancreatic duct (Fig. 1a). On the basis of past history and current evaluation, a presumptive diagnosis of pancreatic fluid collection was made. However, on carefully reviewing the CECT image, right hydronephrosis was visible (Fig. 1b). Delayed films revealed extravasation of contrast from the right renal pelvis into the collection (Fig. 2a,b). Aspiration of cyst fluid showed clear watery fluid with normal amylase level (107 IU/ L) and raised creatinine level (16.4 mg/dL), thereby confirming the diagnosis of urinoma, that is, an encapsulated collection of urine. The child was managed with percutaneous nephrostomy; following which, repeat CT abdomen showed complete resolution of the collection (Fig. 3a,b). Urinary obstruction due to a variety of causes like stones, malignancies, and strictures can lead to urinoma. Uncommonly, injury to the ureter due to trauma, surgery, or therapeutic interventions can cause urine leakage. In the present case, there was no obvious renal or ureteric pathology during previous imaging. With a background of pancreatitis, we suspected the fluid collection to be of pancreatic origin. However, normal serum pancreatic enzymes and a dilated right renal pelvis provided early clues regarding the origin of fluid collection. Delayed films at 30–45 min confirmed the extravasation of contrast from renal pelvis into the cyst cavity. It is important to differentiate between urinoma and pancreatic fluid collection as management differs.