To the editor:
Adults with polycystic liver and kidney disease have cysts in the kidneys and, in many cases, asymptomatic cysts in the liver, pancreas, ovaries, and spermatic duct.1,2 A patient with polycystic kidney disease and pancreatic cysts who experienced acute pancreatitis is reported.
The patient was a 47-year old male without no toxic habits. He had been on regular haemodialysis since September 2006 due to adult polycystic liver and kidney disease, and had underwent nephrectomy because of multiple complications derived from his renal cysts (infections, ruptures¿).
The patient reported nausea, vomiting, severe abdominal pain, and loose stools.
The most common extrarenal complications in polycystic kidney disease include cerebral aneurysms, hepatic cysts, cardiac valve disease, colonic diverticulosis, and abdominal and inguinal hernias.3
Physical examination revealed diffuse abdominal pain, liver increased of size, and peristalsis with no signs of peritoneal irritation.
Laboratory tests showed the presence of high amylase, lipase, and CRP levels and triglyceride levels of 218 mg/dL, with normal bilirubin, transaminase, LDH, and alkaline phosphatase values. Electrocardiogram was normal. No changes were seen in chest and abdominal X-rays.
Antibiotic coverage and fluid therapy were started, and absolute diet was maintained.
A picture of severe abdominal pain in epigastrium and the periumbilical region, often irradiating to the back, nausea, and high serum amylase or lipase levels usually confirms diagnosis of pancreatitis. Fever and ST decreases in the electrocardiogram are not uncommon.
While the main causes of pancreatitis are stones, alcohol consumption, high triglyceride levels, drugs, etc., it should also be considered in the differential diagnosis of abdominal pain in patients with polycystic kidney disease.4
Ultrasonography revealed a liver consistent with liver steatosis or chronic liver disease, with multiple cystic lesions. No stones were seen in the gallbladder. The bile tract was not dilated. Several cysts up to 2.6 cm in diameter were seen in the pancreas. Bilateral nephrectomy was performed.
A CT scan of the abdomen identified a cystic mass with a multilobulated contour in the pancreatic neck region, approximately 4.7 x 3.7 cm in size, that dilated the pancreatic duct at pancreas body and tail level (fig. 1).
An echoendoscopy confirmed the presence of multiple thin-walled, anechoic cysts of various sizes with no solid contents in the pancreas head and isthmus causing a 5-mm dilation in the Wirsung¿s duct.
No fever or leukocytosis was found at any time. The maximum amylase, lipase, and CRP levels achieved were 628 U/L, 8806 U/L, and 70 mg/L respectively. These concentrations subsequently decreased gradually during the course, abdominal pain improved, and oral diet could be restarted at 4 days with good tolerance.
The final diagnosis was acute pancreatitis, probably obstructive in nature. As this was the first episode of pancreatitis, and given the clinical and laboratory improvement, a continued watching attitude was decided, but if the patient should experience a new episode in the future4 or evidence of chronic pancreatitis occurred,5 more aggressive measures already used at hepatic level,6 such as cyst aspiration and sclerosis, surgical or laparoscopic treatment, transplant, etc. would be considered.
We think this is an interesting case, because pancreatic extrarenal cysts are usually asymptomatic.
