Download - Surgical Pathology & X-rays for M edical Students 2007 GIT-2 Liver & biliary system Pancreas Spleen
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Surgical Pathology & X-raysSurgical Pathology & X-raysfor for
MMedical Studentsedical Students20072007
GITGIT-2-2Liver & biliary system
Pancreas
Spleen
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Gall bladder & Bile ducts
Gall stones
Gall bladder imaging
• US
• Oral cholecystography
• Plain X-ray
Types of gall stones
Complications of gall stones
Bile ducts imaging
• US
• CT
• ERCP
Biliary stones
Bile duct CA
• PTC
• ‘T’ tube cholangiography
• Operative cholangiography
• MRCP
Diagnostic patterns of biliary obstruction
Liver
Multiple lacerations
Cirrhosis
Hepatoma
Liver secondary
Liver infections
• Ascending cholangitis
• Liver abscess
• Hydatid cyst
Pancreas
Pancreatic carcinoma
Pseudo-pancreatic cyst
Spleen: Traumatic rupture
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Gall Gall bladderbladder
& &
Bile Bile ductsducts
INDEX
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Gall stonesGall stones(cholelithiasis)(cholelithiasis)
INDEX
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Real time sonographyReal time sonography. Oral cholecystography (OCG), Plain filmsCT and radionuclide studies
GALLBLADDER - GALLBLADDER - IMAGING TECHNIQUESIMAGING TECHNIQUES
INDEX
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LiverLiver
G.B.G.B.Hepatic ductHepatic duct
The gall bladder size and shape are regular with no stones inside. Normal diameter of the bile ducts
Normal US of Normal US of the liver, GB & the liver, GB &
bile ductsbile ducts
US:US: is the most common method used to examine
the morphology and pathology of the liver and GB.
It is the primary screening modality for gallbladder disease
INDEX
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US showing normal GB US showing normal GB
1-1- Distended in a fasting patient
2-2- Contracted in a postprandial patient
INDEX
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Solitary stone Gall Bladder with posterior acoustic shadowing
INDEX
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Solitary stone Gall BladderSolitary stone Gall Bladder
INDEX
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Abdominal Ultrasound: CholelithiasisAbdominal Ultrasound: Cholelithiasis
Multiple, discrete echogenic foci within the gallbladder with posterior acoustic shadowing. The foci were shown to move with change in patient position.
INDEX
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Two round, echogenic stones (arrows) with an acoustic shadow are seen in the normal-sized gallbladder
INDEX
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Real time sonography.
Oral cholecystography (OCG),Oral cholecystography (OCG), Plain filmsCT and radionuclide studies
GALLBLADDER - GALLBLADDER - IMAGING TECHNIQUESIMAGING TECHNIQUES
INDEX
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Normal Oral Oral cholecystographycholecystography (OCG)
INDEX
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ORAL CHOLECYSTOGRAPHY (OCGOCG):
stones filling defects
INDEX
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Oral cholecystography
Multiple gall bladder stones
INDEX
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Real time sonography. Oral cholecystography (OCG),
Plain filmsPlain filmsCT and radionuclide studies
GALLBLADDER - GALLBLADDER - IMAGING TECHNIQUESIMAGING TECHNIQUES
INDEX
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AP plain X-ray RT. AP plain X-ray RT. hypochondrium:hypochondrium:
Several, small, calcified stones can be seen in the area of the elongated gallbladder, which is probably totally filled with stones.
INDEX
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Plain X-ray Plain X-ray film of the film of the abdomen- abdomen- showing multiple calcified gallstones in the Rt. upper quadrant
INDEX
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Plain X-ray film of Plain X-ray film of the abdomen- the abdomen- showing multiple calcified faceted gallstones outlining the contours of the gallbladder in the Rt. upper quadrant
INDEX
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Plain X-ray- Porcelain gallbladderPlain X-ray- Porcelain gallbladder
Elliptical ring-like calcification in the RUQ which corresponds to the shape and location of the gallbladder, the characteristic appearance of porcelain gallbladder.
INDEX
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Porcelain gallbladderPorcelain gallbladder
A calcified gallbladder wall can be asymptomatic.
Gallstones are almost always present in cases of gallbladder calcification.
Considered a result of low-grade chronic inflammation.
Increased incidence of gallbladder carcinoma warrants prophylactic cholecystectomy
INDEX
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Real time sonography. Oral cholecystography (OCG), Plain films
CT and radionuclide studiesCT and radionuclide studies
GALLBLADDER - GALLBLADDER - IMAGING TECHNIQUESIMAGING TECHNIQUES
INDEX
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GB mass GB mass withwith cancer head pancreas cancer head pancreas
GB massGB mass
Cancer head Cancer head pancreaspancreas
INDEX
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GB massGB mass
INDEX
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Types of gallstonesTypes of gallstones
1.Cholesterol stones (Often solitary)
2.Mixed stones (multiple, often faceted) [90% of gallstones]
3.Pigment stones (calcium bilirubinate)
INDEX
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Mixed stonesMixed stones
Mixed stones account to 80 – 90 % of gallstones
Mainly formed of cholesterol
10% of gallstones are radio-opaque
INDEX
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In the gall bladder:
Chronic cholecystitis
Acute cholecystitis
Gangrene, perforation
Empyema – Mucocele
Carcinoma
In the bile ducts:
Obstructive jaundice
Cholangitis
Acute pancreatitis
In the intestine:
Acute intestinal obstruction ( Gallstone ileus)
Effects & complications of gall stones:Effects & complications of gall stones:
INDEX
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Multiple mixed faceted GB stones with chronic calcular cholecystitis
Complications of gall stones in the gall bladdergall bladder
INDEX
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Gallstones (cholelithiasis)Gallstones (cholelithiasis)
Chronic calcular cholecystitisChronic calcular cholecystitis
INDEX
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Mixed Mixed GallstonesGallstones
Pigment Pigment GallstonesGallstones
INDEX
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Chronic cholescystitis with cholelithiasisNote the thickened gallbladder wall.
INDEX
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Autopsy specimen (of another patient)
SS: impacted stone
LL: liver
USUS:
Marked dilatation of the GB
Mucocele – Hydrops of GBMucocele – Hydrops of GB
INDEX
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Empyema of GBof GBThe GB is filled with bile stained pus & stones
The cystic duct is opened to show impacted stone
The GB wall is thick & fibrotic with congestion & erythema of the serosa (acute on top of chronic inflammation)
Inflamed omentum surrounds the inflamed GB
INDEX
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This tumor is uncommon but invariably associated with the presence of gallstones
Carcinoma of the gallbladderCarcinoma of the gallbladder
INDEX
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Obstructive jaundiceObstructive jaundice
More ERCP pictures will come later
Complications of gall stones in the bile ductsbile ducts
INDEX
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A gallstone obstructing the cystic duct and resulting in inflammation and compression of the common bile duct.
The symptoms and signs involve jaundice and pain.
The diagnosis and treatment involve ERCP
Mirizzi's SyndromeMirizzi's Syndrome
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ERCPERCP cholangiogram showing dilated CHD and intra-hepatic ducts with normal CBD and filling defect at cystic duct/CBD junction
More pictures for ERCP will come later
Mirizzi's SyndromeMirizzi's Syndrome
INDEX
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Pyogenic abscesses of the liver secondary to acute cholangitisExtension of the pyogenic process through the biliary tree
CholangitisCholangitis
INDEX
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Acute pancreatitis
INDEX
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70 y old female with known history of gallbladder stones
Vomiting & abdominal pain 2 days before admission
Plain X-ray showing mechanical small bowel obstruction, gall stone shadow & aerobilia
Gall stone ileusGall stone ileus
Complications of gall stones in the IntestineIntestine
INDEX
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Imaging of the Biliary Ducts.Imaging of the Biliary Ducts.
INDEX
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Non-invasive Non-invasive
screeningscreening for for suspected biliary suspected biliary ductal pathologyductal pathology
USUS
Direct opacification Direct opacification of the ductsof the ducts
PTC PTC
ERCPERCP
Postoperative T-Tube cholangiography
Intraoperative cholangiography
Intravenous cholangiography (IVC) is considered an outdated technique
Biliary scintigraphy, while very useful in the diagnosis of acute cholecystitis, has a limited role in the diagnosis of biliary ductal disease
CTCT
The initial imaging technique when biliary obstruction is suspected
Reserved for selected cases in which more information about levellevel and causecause of obstruction is needed
INDEX
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ULTRASOUND:ULTRASOUND:
INDEX
The common bile duct (3,8 mm) and the portal vein are of normal diameter. The intrahepatic bile ducts are also normal
Portal Portal veinvein
Common bile ductCommon bile duct
Normal Normal liverliver
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COMPUTED TOMOGRAPHY (CT)COMPUTED TOMOGRAPHY (CT)
CT is reserved for selected cases which are equivocal on sonography or in which more information about level and cause of obstruction is needed
Mass in the head of pancreas causing biliary obstruction &
huge BG dilatation
Small mass in the pancreas causing dilatation of the common bile duct (cbd)
& pancreatic duct (pd)
INDEX
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INDEX
ERCP:ERCP:EEndoscopic rretrograde ccholangioppancreatography
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Normal Normal ERCPERCP
Common bile ductCommon bile duct
Gall bladder
Common hepatic ductCommon hepatic duct
Rt. & Lt. hepatic ductsRt. & Lt. hepatic ducts
INDEX
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ERCP- ERCP- CholedocholithiasisCholedocholithiasis
Common duct stones
Dilated common bile duct to the level of the head of the pancreas.
In the dilated CBD is a radio-lucent stone (round, radiolucent filling defect) (arrow).
INDEX
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Endoscopic biliary sphincterotomy with stone removal
INDEX
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CBD stone extracted by Dormia basketCBD stone extracted by Dormia basket
Following sphincterotomy, the stone is extracted using a wire basket (Dormia Basket)
Common duct stones may also be identified on T-Tube cholangiography and operative cholangiography. The appearance is the same as on PTC or ERCP
INDEX
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ERCP:ERCP:
The contrast material fills the dilated intrahepatic and common bile duct, in which several filling defects (gallstones) are visible (arrows)
INDEX
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ERCPERCP
Stone CBDStone CBD
INDEX
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ERCPERCP
Stones CBDStones CBD
INDEX
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ERCPERCP
Stone CBDStone CBD
INDEX
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ERCPERCP
Stone CBDStone CBD
INDEX
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Bismuth classification of Bismuth classification of hilar hilar CholangiocarcinomaCholangiocarcinoma
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ERCP- bile duct carcinomaERCP- bile duct carcinoma
A short segment constricting lesion with irregular margins was noted at the bifurcation of the common hepatic duct (arrow).
This high-grade constricting lesion at the hepatic duct is consistent with a primary bile duct bile duct carcinomacarcinoma, or Klatskin tumorKlatskin tumor.
INDEX
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Stent inserted endoscopically in CBD
The previous patient was inoperable.
A stent was inserted for palliative relief of jaundice.
INDEX
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Klatskin’s tumor: Bile duct carcinomaKlatskin’s tumor: Bile duct carcinoma
INDEX
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PTCPTC: PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY
INDEX
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Normal Normal PTCPTC
INDEX
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PTCPTC - stone lower CBD
INDEX
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PTC:PTC:
The contrast material administered through a Chiba needle (arrows) completely fills the intrahepatic bile ducts, extremely dilated because of an obstruction of the common bile duct.
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T-TUBE CHOLANGIOGRAPHY:T-TUBE CHOLANGIOGRAPHY:
INDEX
Normal
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Normal T-tube cholangiography
Notice the free passage of contrast into the duodenum
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Normal T-tube cholangiography
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Radiologic extraction of retained common duct stone
The T-Tube cholangiogram
It shows a meniscoid filling defect in the distal common duct occluding flow. This represents a retained common duct stone.
The T-Tube was left in place to allow formation of a firm tract and the patient returned 5 weeks later (6 weeks after surgery) for radiologic extraction of the stone through the T-Tube tract. INDEX
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Stone engaged in the basket (curved arrow) and being removed from the duct via the T-Tube tract.
A post-procedure cholangiogram should be done to confirm that the duct is clear with no residual stone or fragments
Radiologic extraction of the stone through the T-Tube tractRadiologic extraction of the stone through the T-Tube tract
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OPERATIVE CHOLANGIOGRAPHYOPERATIVE CHOLANGIOGRAPHYThe bile duct is opacified during operative cholangiography by inserting a needle or cannula directly into the cystic duct or CBD and injecting contrast material
This procedure is done at the time of cholecystectomy to assess for stones in the bile ducts to determine the need for common duct exploration
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MRCPMRCP (normal)
(Magnetic resonance cholangio-panceriatography)
Advantages of MRCP:
Non invasive (avoids complications of diagnostic ERCP or PTC)
No sedation usually required
No iodinated intravenous contrast (avoids iodine anaphylaxis and contrast nephropathy)
Rapid scan time
No ionising radiation (safe in pregnancy and children)
Delineates ductal anatomy proximal to obstructions
Delineates anatomy post biliary-enteric anastomosis Define extraductal structures (useful in staging malignancy) INDEX
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MRCPMRCP
Normal anatomy
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MRCPMRCP
showing 2 showing 2 CBD stones & CBD stones & dilated CBDdilated CBD
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MRCPMRCP demonstrating a demonstrating a hilar cholangiocarcinomahilar cholangiocarcinoma. .
There is a stricture and obstruction at the hilum with intrahepatic There is a stricture and obstruction at the hilum with intrahepatic biliary dilatationbiliary dilatation
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M.R. M.R. cholangiography cholangiography showingshowing
CHD injury with CHD injury with collectioncollection
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DIAGNOSTIC PATTERNS DIAGNOSTIC PATTERNS of of
BILIARY OBSTRUCTIONBILIARY OBSTRUCTION
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Types of BILIARY OBSTRUCTION.Types of BILIARY OBSTRUCTION.
1.1. Choledocholithiasis Choledocholithiasis (biliary duct stones)
One or more
intraluminal defects (round, faceted or lobulated) which produce varying degrees of biliary obstruction are seen. Occasionally stones are noted as small multiple free-floating defects in a non-dilated duct.
INDEX
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2.2. Pancreatic carcinoma Pancreatic carcinoma Complete or almost complete obstruction of the mid or distal common duct, usually over a long segment (3-4 cm) of the distal duct (intrapancreatic portion) is seen.
A "rat-tail" configuration is the typical appearance (red arrows);
however, a rounded end or short segment stenosis with more abrupt margins may be seen.
INDEX
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Adenocarcinoma of the pancreasTumors in the head of the pancreas tend to obstruct the bile duct
Duodenum: DUDU
Cancer head of pancreas: CHPCHP
INDEX
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3.3. Cholangiocarcinoma Cholangiocarcinoma The narrowing may occur at any level and typically presents as a short segmental stenosis. When the lesion is located at the bifurcation, it is referred to as a Klatskin tumor
Cholangiocarcinoma may be polypoid or diffusely infiltrating.
INDEX
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4. Benign strictureBenign stricture
There is a short segmental circumferential stricture in the mid-common duct in a patient with a previous cholecystectomy.
Most benign strictures are secondary to ductal injury during cholecystectomy. (iatrogenic)
INDEX
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5.5. Ampullary carcinoma Ampullary carcinoma
Focal obstruction of very distal CBD is noted.
A smooth constriction or an irregular polypoid mass growing into distal CBD may be seen.
INDEX
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6. Chronic pancreatitis Chronic pancreatitis causing stricturecausing stricture:
A long segment stricture of the intrapancreatic common duct is seen.
The stricture is more tapered than that seen in pancreatic carcinoma and does not usually completely obstruct. Calcifications in the pancreatic head help confirm the diagnosis.
8. Metastatic nodes to the porta Metastatic nodes to the porta hepatishepatis - Infiltration or encasement of the CHD, usually just below the bifurcation, is seen.
The obstruction tends to be short segmental, smooth, concentric and occurs in a patient with a clinical history of primary neoplasm elsewhere.
7. Sclerosing cholangitisSclerosing cholangitis There is a diffuse periductal
infiltrating lesion involving the intra- and extrahepatic ducts with beading, irregularity and segmental narrowing.
Other causes of biliary obstructionOther causes of biliary obstruction
INDEX
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Ascariasis worms causing obstructive jaundice
INDEX
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AscariasisWorms are seen extending through the common bile duct and major hepatic ducts
INDEX
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LiverLiver
INDEX
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•Massive abdominal blunt force injury often leads to liver injury, since it is the largest internal organ. Note the multiple lacerations seen here over the capsular surface of the liver.
•Crush injuries can damage abdominal organs causing lacerations or rupture with bleeding into the peritoneal cavity (hemoperitoneum) Peritoneal lavage can detect such bleeding
Multiple hepatic lacerations
INDEX
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Intraoperative photograph of the right hepatic lobe (In another patient)
Exploration should look for other injuries.Exploration should look for other injuries. In this patient, the missile traversed the liver and injured the right kidney, which required removal due to sever hemorrhage.
The hepatic injury, was successfully managed with debridement of non-viable parenchyma, ligation of arterial vessels on the raw surface, viable omental packing, and drainage.
Liver Liver injury due injury due to gun to gun shotshot
Free intraperitoneal fluid adjacent to the liver (black arrowheads) with laceration (curved arrow) to the anterior left lobe of liver.
Air (white arrowhead) is seen within muscle anterior to the liver injury (entry site)
INDEX
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Liver cirrhosisLiver cirrhosis
INDEX
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Portal venous systemPortal venous systemCP of portal CP of portal
hypertension with liver hypertension with liver cell failurecell failure
INDEX
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Esophageal varices as
seen in upper GI endoscopy
Caput MedusaePortal hypertension leads to expansion of collateral veins in the region of the
umbilicus
Splenomegaly on laparoscopy
What are the manifestations of
portal hypertension?
INDEX
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© GIT 290Chronic alcoholism leads to fibrosis and regeneration of the hepatocytes in nodules. This firm, nodular appearance of the liver as seen here is called cirrhosis
Macro-nodular cirrhosis
INDEX
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Macro-nodular cirrhosis
INDEX
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Biliary cirrhosis
INDEX
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Liver cirrhosis Liver cirrhosis as seen during an operationas seen during an operation
Liver
Stomach
INDEX
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HepatomaHepatomaHepatocellular carcinoma .
A primary liver cancer that starts in the liver cells
INDEX
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Hepatocellular carcinoma (hepatoma)
(solitary large mass)
Note: cirrhosis; bulging,
pigmented hepatoma
INDEX
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Solitary hepatic Solitary hepatic nodule for D.D.nodule for D.D.
INDEX
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HepatomaHepatoma
INDEX
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Secondaries in the LiverSecondaries in the Liver
INDEX
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Multiple liver secondariesMultiple liver secondaries
INDEX
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CT scan with CT scan with intravenous contrastintravenous contrast
Multiple low density area suspicious of metastasis .
The commonest tumour in the liver is metastasis. The primary tumour may The primary tumour may commonly arise from the commonly arise from the lunglung, , breastbreast, , coloncolon, , stomachstomach and and pancreaspancreas.
Multiple liver Multiple liver metastasismetastasis
INDEX
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Multiple liver Multiple liver metastasismetastasis
INDEX
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Multiple liver metastasisMultiple liver metastasis
INDEX
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Multiple liver metastasisMultiple liver metastasis
INDEX
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Multiple liver metastasisMultiple liver metastasis
INDEX
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© GIT 2106
Multiple liver metastasisMultiple liver metastasis
INDEX
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Multiple liver metastasisMultiple liver metastasis
INDEX
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Numerous, mostly round-shaped hypodens lesions of different size are visible in both lobes of the liver.
Liver metastasisLiver metastasis
INDEX
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Liver Liver InfectionsInfections
Viral hepatitis
Ascending cholangitis
Pyogenic liver abscess
Amoebic live abscess
Hydatid liver disease
INDEX
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Ascending cholangitisAscending cholangitis
Pyogenic abscesses of the liver secondary to acute cholangitis
INDEX
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Chest radiograph demonstrating elevation of the right hemidiaphragm
Abdominal CT scan demonstrating a large abscess in the right hepatic lobe
Liver abscessLiver abscess
The clinical picture & lab investigations should ALWASYS be correlated to the US & CT findings
INDEX
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Amebic liver abscessAmebic liver abscess
Entameba histolytica
The ingested cyst reaches the intestine
The active trophozoite form in the colon can reach the liver via the portal blood (Extra-intestinal disease)
INDEX
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A 24-year-old male presented with 3 weeks history of fever, malaise, nausea, vomiting and right upper quadrant pain.
Bowels were regular with normal stools.
General examination: he was febrile (38oC)but vital signs were stable.
He was not anemic or jaundiced. Chest & heart examination was normal
Abdominal examination: right upper quadrant tenderness without rigidity or guarding.
No organomegaly, masses, or ascites and bowel sounds were normal
Investigations: CBC: raised WBC (13.200) and ESR (96 mm/hr). Liver functions showed elevated alkaline phosphatase (152 IU/L) and a low albumin (3.0 g/dL).
Amebic serology (Indirect Haemagglutination test) was positive
Abdominal US showed homogenous hypoechoic lesion with well-defined borders
Abdominal CT scan showed a well- demarcated abscess in the right lobe of liver
Diagnosis: Amebic liver abscess INDEX
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Clinical HistoryClinical History: 30 y old male with right upper quadrant pain and fever of 2 weeks duration
CTCT: Hypodense lesion within the posterior segment of the right lobe of the liver.
There is a peripheral region of increased density surrounding the hypodense lesionIf no wall is seen, the differential diagnosis would include: amebic liver abscess, pyogenic abscess, echinoccocal cyst, hematoma, or necrotic tumor.
If an enhancing wall is present (as in this case) the differential should be limited to inflammatory conditions Liver abscess that proved to be amebicLiver abscess that proved to be amebic
INDEX
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© GIT 2115
Pyogenic liver abscessPyogenic liver abscess
Usually in elderly, diabetics & immunosuppresed patients
Clinically, there is fever, malaise with upper Rt. quadrant discomfort
A multiloculated cystic mass is found on US & CT
Diagnosis is confirmed by guided aspiration. The aspirated material is sent to culture & sensitivity
Treatment is antibiotics & US guided aspiration
Blind percutanous aspiration may go through the pleural space & cause empyema
DD:DD: amebic liver abscess, pyogenic abscess, echinoccocal cyst, hematoma, or necrotic tumor or metastasis
The clinical picture & lab investigations should ALWASYS be correlated to the US & CT findings
INDEX
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Liver abscess Liver abscess (proved to be amebic)
INDEX
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Liver abscessLiver abscess
INDEX
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Hydatid Cyst Hydatid Cyst
of the liverof the liver
INDEX
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© GIT 2119
Liver with a hydatid cyst containing fluid and daughter cysts.
Notice the thick connective tissue capsule
INDEX
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Hydatid CystHydatid Cyst
Echinococcus granulosusEchinococcus granulosus ( Tapeworm) infection of the liverHydatid cysts develop calcium in their wall which may be seen on a routine chest x-ray. INDEX
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US: US:
A septated, round, unechoic area, can be seen in the liver parenchyma
Hydatid CystHydatid Cyst
INDEX
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CT:CT: Multivesicular hydatidhydatid with multiple daughter cysts giving a septated appearance
INDEX
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PancreasPancreas
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The pancreas is bisected along its longitudinal axis revealing a large adenocarcinoma (B) of the head. (A) is the tail of pancreas
Cancer head of pancreasCancer head of pancreas
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High- grade stenosis of the lower biliary duct with a prestenotic dilatation of the CBD
ERCPERCP:
Cancer head pancreas CBD dilatation
Irregular high- grade stenosis
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Cancer head Cancer head of pancreasof pancreas
Liver
Pancreas body
Cancer head
Kidney
IVC
Aorta
CT CT examinationexamination
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Liver
Gall bladder (markedly dilated)
Cancer head
Kidney
IVC
Aorta
Patients with obstructive jaundice & Patients with obstructive jaundice & GB massGB mass – think of malignant obstruction – think of malignant obstruction
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Notice the relation of the mass to the duodenum & inferior venacava
An irregular mass in the head of the pancreas
Cancer head Cancer head pancreaspancreas
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Ba meal showing pancreatic pseudocyst compressing the stomach
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Acute hemorrhagic pancreatitis Acute hemorrhagic pancreatitis
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SpleenSpleen
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Splenic lacerationsSplenic lacerations
Splenic rupture should be suspected after any trauma specially if associated with direct injury to the left upper quadrant. The possibility of injury increases if the spleen is diseased or enlarged.
The spleen is the most common organ to be injured in blunt abdominal trauma
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A large crescentic, low-density fluid collection along the lateral aspect of the spleen.
Flattening of the normal splenic contour
CT abdomenCT abdomen
Traumatic sub-capsular hematoma
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Splenic Splenic lacerationslacerations
CT abdomenCT abdomen
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Traumatic rupture Traumatic rupture sspleen & Lt. pleen & Lt. kkidneyidney
Hematoma: HHSpleen: SS Kidney: KK
SS
KK
HH
HH
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Pseudopanceriatic cyst & Splenic hematomaPseudopanceriatic cyst & Splenic hematoma
L: Liver
P: Pancreas
PS: Pseudopancreatic cyst
S: Spleen
H: Hematoma
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