Blunt Costophrenic Angle in a Patient with Pancreatitis
Am Fam Physician. 2021 May 15;103(10):625-627.
A 40-year-old patient presented with new-onset abdominal pain, nausea, and vomiting. The patient did not have fever, diarrhea, or changes in bowel movements. The medical history included hypertension, anxiety, obstructive sleep apnea, and recurrent pancreatitis complicated by pancreatic necrosis secondary to chronic alcohol abuse.
Initial laboratory findings included elevated lipase and mildly elevated triglyceride levels consistent with recurrent pancreatitis. The patient was admitted for initiation of intravenous fluids, nutritional support, and pain management but was transferred to a tertiary care center after developing a fever, shortness of breath, and a need for supplemental oxygen. Physical examination revealed diminished breath sounds at the right lung base. Chest radiography was obtained (Figure 1).
Based on the patient's findings, which one of the following is the most likely diagnosis?
B. Hemidiaphragm paralysis.
C. Lobar pneumonia.
D. Pleural effusion.
E. Subphrenic pancreatic pseudocyst.
The answer is E: subphrenic pancreatic pseudocyst. The chest radiograph showed a large right-sided pleural effusion and blunting of the costophrenic angle. Point-of-care ultrasonography performed in preparation for thoracentesis did not reveal any appreciable pleural effusion. A subsequent computed tomography (CT) scan of the chest, abdomen, and pelvis (Figure 2) demonstrated a loculated, complex, proteinaceous fluid collection measuring 14 cm × 13 cm × 12 cm (estimated volume = 1,100 mL) in the right subphrenic space, which was compressing the right liver lobe and surrounding structures. Fluid obtained through fine-needle aspiration guided by endoscopic ultrasonography showed very high amylase content and a low carcinoembryonic antigen level, which are consistent with a pancreatic pseudocyst.
Referencesshow all references
1. Habashi S, Draganov PV. Pancreatic pseudocyst. World J Gastroenterol. 2009;15(1):38–47....
2. Demeusy A, Hosseini M, Sill AM, et al. Intrahepatic pancreatic pseudocyst: a review of the world literature. World J Hepatol. 2016;8(35):1576–1583.
3. Topno N, Ghosh S, Baruah A. A rare case report of hepatic subcapsular pseudocyst of pancreas. J Clin Diagn Res. 2016;10(12):PD18–PD19.
4. Les I, Córdoba J, Vargas V, et al. Pancreatic pseudocyst located in the liver. Rev Esp Enferm Dig. 2006;98(8):616–620.
5. Gupta D, Pipaliya N, Pandav N, et al. Intrahepatic pancreatic pseudocyst: case series. JOP.J Pancreas. 2016;17(4):410–413.
6. Barry K. Chronic pancreatitis: diagnosis and treatment. Am Fam Physician. 2018;97(6):385–393. Accessed March 25, 2021. https://www.aafp.org/afp/2018/0315/p385.html
7. Rudrappa M, Paul M. Chylothorax. StatPearls. Updated January 25, 2021. Accessed March 27, 2021. https://www.ncbi.nlm.nih.gov/books/NBK459206/
8. McCool FD, Tzelepis GE. Dysfunction of the diaphragm [published correction appears in N Engl J Med. 2012; 366(22):2138]. N Engl J Med. 2012;366(10):932–942.
9. Kaysin A, Viera AJ. Community-acquired pneumonia in adults: diagnosis and management [published correction appears in Am Fam Physician. 2017;95(7):414]. Am Fam Physician. 2016;94(9):698–706. Accessed March 25, 2021. https://www.aafp.org/afp/2016/1101/p698.html
10. Saguil A, Wyrick K, Hallgren J. Diagnostic approach to pleural effusion. Am Fam Physician. 2014;90(2):99–104. Accessed March 25, 2021. https://pubmed.ncbi.nlm.nih.gov/25077579/
This series is coordinated by John E. Delzell Jr., MD, MSPH, associate medical editor.
A collection of Photo Quiz published in AFP is available at https://www.aafp.org/afp/photoquiz.
The editors of AFP welcome submissions for Photo Quiz. Guidelines for preparing and submitting a Photo Quiz manuscript can be found in the Authors' Guide at https://www.aafp.org/afp/photoquizinfo. To be considered for publication, submissions must meet these guidelines. E-mail submissions to firstname.lastname@example.org.
Copyright © 2021 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact email@example.com for copyright questions and/or permission requests.
Want to use this article elsewhere? Get Permissions