As such a cyst attains marked size it will displace the adjoining viscera, pushing the diaphragm upward and impeding heart and lung action, obstructing the pylorus and duodenum and causing gastric dilatation, pressing upon the intestines and perhaps even compressing the ureters, thus producing hydronephrosis. Other peculiar pressure effects may be met in particular instances. A sudden increase in size indicates a fresh hemorrhage, which may lead to its rupture and to death from peritonitis. These cysts rarely empty spontaneously into the bowel. Their contents are liable to infection, and thus a cyst may become converted into a large abscess.
Symptoms.
—Symptoms include especially pain, which may have been sudden, but becomes more or less constant, accompanied by a sense of oppression, according to the size and the pressure effects produced in each case. Digestion is always more or less disturbed; this may be attributed to the stomach dilatation, which is itself a sequel of the condition. The stools show little which is significant save that they are occasionally bloody. Undigested muscle fiber would indicate loss of pancreatic function. Other symptoms will vary so much with individual cases that it is not necessary to consider them here.
The physical signs, coupled with a suggestive history, especially one which includes an account of injury, are of the greatest importance in diagnosis. These physical signs will include usually a yellowish tinge of the skin, marked emaciation, dry skin, and the presence of a tumor in the upper abdomen, which is usually centrally placed, but not necessarily so. If the patient has carefully noted the development of his own symptoms it will be found that the enlargement commenced above and usually a little to the left, and developed in other directions from that location. Palpation reveals a smooth, elastic, usually fluctuating tumor, sometimes movable with respiration, rarely pulsating.
It must be remembered that a pancreatic cyst may rise above the stomach, may rest entirely behind it, or may protrude either below it and above the colon or else quite below the colon. Distention of the stomach will afford accurate location, in these respects, upon percussion, while percussion without distention may mislead. A tumor which gives dulness below the stomach and above the colon is extremely suggestive.
Diagnosis.
—Diagnosis by aspiration is inadvisable, even dangerous, for death has followed the introduction even of a needle into such a cyst. Aspiration, then, should be reserved for tumors already exposed through an abdominal incision.
For the purpose of differentiation it will suffice here to remind that tumors of the kidney, as well as hydronephrotic cysts, grow downward and forward from the loin, and can be pushed backward to their proper place unless too large, that they are not accompanied by digestive disturbances, while the urine is usually more or less indicative. A hydronephrotic cyst can scarcely be made to occupy a position between the stomach and the colon and present in the middle line in front. Ovarian cysts rise from the pelvis and will rarely occur in the upper location, save those provided with extremely long pedicles. Hydatid cysts of the liver show a continuity and fixation to that viscus which are usually diagnostic.
Treatment.
—The only treatment for pancreatic cysts is surgical, it remaining with the surgeon to decide as between drainage and extirpation. While it is indisputable that extirpation is the ideal method of dealing with all cysts and tumors, most of these cases are of such long duration that the adhesions contracted between their exteriors and the surrounding viscera are so dense and firm that much greater danger attaches to a radical operation than to one for simple incision and drainage. I have been able in at least one case to completely extirpate such a cyst, but it was one exceedingly favorably situated and surrounded.