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Lesions of the Pancreas Mimicking Renal Disease
THE JOURNAL OF UROLOGY
Vol. 93, No. 1 January 1965 Copyright © 1965 by The Williams & Wilkins Co.
Printed in U.S.A.
LESIONS OF THE PANCREAS MIMICKING RENAL DISEASE SUMNER MARSHALL, MAURICE LAPP
AND
JOHN W. SCHULTE
From the Division of Urology, Department of Surgery, University of California Medical Center, San Francisco, California
Because of the intimate anatomical relationship of the kidneys and pancreas within the retroperitoneal cavity, it is not uncommon for spaceoccupying lesions of the pancreas to encroach directly on the kidneys or ureters and to produce both symptoms and radiological changes suggestive of a primary lesion of the urinary tract. 1 - 5 The pancreas, like the kidneys, is essentially a retroperitoneal organ and is situated transversely across the posterior wall of the abdomen (fig. 1). Anteriorly and inferiorly, it is closely associated with the duodenum, transverse colon, and stomach. The posterior surface, being devoid of peritoneum, is in direct contact on the right with the inferior vena cava, the right renal vein, and Gerota's fascia of the right kidney. On the left, it traverses the aorta and left renal artery, and extends upward toward the spleen, crossing the upper part of the kidney. This intimate anatomical relationship of the pancreas to the urinary tract, especially to the left kidney, is adequate reason for tumors of the pancreas to mimic diseases of the urinary tract. A series of 13 cases of pancreatic tumors with renal symptoms will be presented here.
chills and fever. Radiographic studies suggested a primary renal lesion (fig. 2); serum amylase was elevated. At operation, a pseudocyst was found arising from the tail of the pancreas and lying above and separate from the kidney. Case 2. A pseudocyst of the tail of the pancreas was manifest clinically in a 23-year-old woman by a fullness in the left upper abdominal quadrant. Serum amylase was elevated. An excretory urogram prior to operation showed downward displacement and a vertical axis of the left kidney. Case 3. A 60-year-old man consulted his physician because of a 2-month history of nausea, vomiting, periumbilical pain and exertional dyspnea. A tender, fixed mass was palpable in the left upper abdominal quadrant. Radiographic studies showed downward displacement of the left kidney (fig. 3,A), anterior displacement of the stomach (fig. 3,B), and a left pleural effusion (fig. 3,C). Microscopic hematuria was present; serum amylase was elevated. Exploratory laparotomy revealed a pseudocyst of the pancreas in the left subdiaphragmatic area with direct extension of this mass to the left renal fossa. Case 4. A 46-year-old man with a 2-year history of intermittent episodes of left flank pain, nausea, and vomiting was found at operation to have a calcified cyst lying anterior to the kidney in continuity with the pancreas (fig. 4). Case 5. Carcinoma of the tail of the pancreas in a 74-year-old man was associated with anorexia, weakness, and left flank pain. Microscopic hematuria was present. Radiographic findings included depression of the left kidney, anterior displacement of the stomach, and a left pleural effusion. Case 6. A 63-year-old man who had experienced episodes of nausea, vomiting, and pain in the left flank for 3 months was noted to have microscopic hematuria. Excretory urography showed incomplete filling of the collecting system suggestive of a space-occupying lesion of the upper pole of the left kidney. At operation this was found to be a large infiltrating tumor arising
CASE REPORTS
Case 1. A 28-year-old man had a 6-year history of episodes of left flank pain, nausea, vomiting, Accepted for publication June 4, 1964. Read at annual meeting of Western Section, American Urological Association, Inc., Coronado, California, February 17-20, 1964. 1 Abeshouse, B. S.: Collective review. The differential diagnosis of pancreatic and renal disease, with particular emphasis on differentiating pancreatic cysts from renal cysts. Int. Abst. Surg., 96: 1-28, 1953. 2 Ormond, J. K., Wadsworth, G. H. and Morley, H. V.: Pancreatic lesions confusing urologic diagnosis. Report of 3 cases. J. Urol., 48: 650-657, 1942. 3 Stone, E. P.: Pancreatic cysts simulating renal disease. J. Urol., 62: 104-117, 1949. 4 Surmonte, J. A., Miller, J. M., Ginsberg, M. and Meisel, H. J.: Pseudocyst of the pancreas simulating disease of the kidney. J. Urol., 81: 606-608, 1959. 5 Thompson, G. J. and Culp, 0. S.: Perplexing cystic masses near the kidney. J. Urol., 89: 370376, 1963. 41
42
MARSHALL, LAPP AND SCHULTE
from the tail of the pancreas with direct extension to the spleen, left adrenal, and upper pole of the left kidney. Case 7. A 55-year-old man entered the hospital with a 3-month history of abdominal pain in the left upper quadrant, vomiting, and a 20-
Fm. 1. Relationship of pancreas to other organs. Note its intimate anatomical relationship to left kidney.
pound weight loss. He was subsequently found to have carcinoma of the tail of the pancreas which, by excretory urography, had been interpreted as a space-occupying lesion of the lower pole of the left kidney (fi@:. 5). Case 8. Carcinoma of the body and tail of the pancreas was found in a 65-year-old man after he had experienced episodes of anorexia and left flank pain for 7 months. Palpation of a firm mass in the left upper abdominal quadrant had caused radiation of pain to the left inguinal region. An excretory urogram showed depression and a shift of the axis of the left kidney (fig. 6,A), which had not been present on urograms obtained 2 months earlier (fig. 6,B). Case 9. A 71-year-old man had a 6-week history of intermittent episodes of nausea, vomiting, and pain in the left upper abdominal quadrant. Radiographic studies showed lateral and downward displacement of the left kidney and anterior displacement of the stomach. At operation an
FIG. 2. Case 1. A, excretory urogram and B, aortogram delineate mass in region of upper pole of left kidney which proved at surgery to be pseudocyst of pancreas. Note distorted calyceal system on urogram and abnormal contour of kidney on nephrogram phase of aortogram.
Fm. 3. Case 3. Pseudocyst of pancreas caused, A, considerable depression of left kidney; B, anterior displacement of stomach; and C, left pleural effusion.
LESIONS OF PANCREAS MIMICKING RENAL DISEASE
adenocarcinoma of the body and tail of the pancreas was found, with direct extension of the tumor to the stomach, transverse colon, spleen, and left adrenal gland. Case 10. A 47-year-old man entered the hospital after a 5-year history of recurrent episodes
Fm. 4. Case 4. Calcified cyst of pancreas appears on excretory urography to be of renal origin.
Fm. 5. Case 7. Carcinoma of tail of pancreas gives appearance on excretory urography of mass of lower pole of left kidney.
43
of nausea, vomiting, and epigastric pain with radiation to the back. Nineteen years previously the patient had had an unexplained episode of total gross hematuria. Excretory urography showed downward displacement of the left kidney which was found at exploratory laparotomy to be caused by carcinoma of the tail of the pancreas. Case 11. A tender, smooth mass measuring 10 cm. in diameter was palpable in a 62-year-old white man who had experienced malaise, anorexia, and a 20-pound weight loss over the previous 6 months. This mass, which was found at operation to be carcinoma of the body and tail of the pancreas, caused a marked depression and exaggerated oblique axis of the left kidney (fig. 7). Case 12. A 31-year-old man had experienced a sensation of abdominal fullness with minimal discomfort over a 4-month period. Pertinent physical findings included a hard, smooth mass in the left upper abdominal quadrant which descended with respiration, and a left varicocele. The left kidney appeared to be markedly displaced when seen on an excretory urogram. Exploratory laparotomy revealed the body and tail of the pancreas to be completely replaced by a tumor. Case 13. Carcinoma of the body and tail of the pancreas was found at operation in a 67-year-old woman who had noticed epigastric pain radiating to the back and a 15-pound loss in weight over the previous year. This palpable mass had been radiographically seen to have caused anterior displacement of the stomach and depression of the left kidney.
Fm. 6. Case 8. A, excretory urogram shows downward and lateral displacement of left kidney by an anaplastic carcinoma of tail of pancreas. B, excretory urogram taken 2 months earlier was felt to be within normal limits.
44
MARSHALL, LAPP AND SCHULTE
Fm. 7. Case 10. Infiltrating carcinoma of pancreas occupying much of left retroperitoneum is seen to markedly depress left kidney, as well as to exaggerate its oblique axis. 1. Summary of pertinent clinical, laboratory and radiographic findings in thirteen cases of pancreatic lesions mimicking urological disease
TABLE
Pertinent Findings
History Gastrointestinal symptoms Urogenital symptoms Physical examination Palpable mass Movable mass Diagnosis after surgery Carcinoma of the pancreas Pancreatic cyst Laboratory data Elevated serum amylase (all cysts) Hematuria (cyst and carcinoma) Radiography I.V.P.: Downward displacement of kidney Calyceal distortion G. I. series: Anterior displacement of stomach
No. Cases
% Cases
13
100%
11
85
8 2
62
9 4
69 31
3
23
3
23
11
85
4 7
54
25
31
DISCUSSION
Table 1 summarizes pertinent clinical, laboratory and radiographic findings in our series. History. All patients in this series had symptoms referable to the gastrointestinal tract, the most common of which were anorexia, nausea, vomiting and abdominal discomfort. Eleven of
these patients had associated complaints of flank pain, suggestive of renal involvement. The symptoms caused by direct encroachment on the kidneys by these lesions are usually indistinguishable from those caused by any irritation of the urinary tract. Because of the common autonomic and sensory innervations of the gastrointestinal and urinary systems, reno-intestinal reflexes are set off by such irritation. Afferent stimuli from the renal capsule or musculature of the pelvis may, by reflex action, cause changes in the tone of the smooth rn.uscles of the enteric tract, with a resultant clinical picture of gastrointestinal disease. 6 Physical examination. Masses were palpable in the left upper quadrant of the abdomen in eight of the 13 cases. Only two of these masses were mobile. Abeshouse1 believes that enlargements of the kidney are palpable and often ballotable in the flank and lumbar areas, whereas pancreatic lesions are less likely to be palpable in these areas. However, most of the lesions in our series involved the tail of the pancreas, which overlies the middle and upper half of the left kidney (fig. 1), thereby presenting themselves frequently in the left upper quadrant of the abdomen and flank. Laboratory tests. Since the serum amylase may be elevated in inflammatory lesions of the pancreas (cases 1, 2, 3), it could aid in the differentiation of pancreatic cysts and renal masses. No such elevation in serum amylase was seen in any of the cases of carcinoma of the pancreas. Microscopic hematuria was present in three of our cases, one with a pseudocyst (case 3) and two with carcinoma (cases 5 and 6). This finding has been noted previously in the literature1 - 3 , 7 and is felt to be secondary to toxic or inflammatory changes in the kidney, independent of or resulting from the pancreatic disease. In cases 3 and 5, there was a significant inflammatory reaction in the left subdiaphragmatic area with the presence of a left pleural effusion in both patients. Direct infiltration of tumor could likewise account for the hematuria (case 6). Ransohoff8 reported a case in which gross hematuria 6 Smith, D. R.: Gastrointestinal symptoms of genitourinary origin. Gastroenterology, 20: 119-
128, 1952.
7 Honigmann, F.: Zur Kenntnis der traumatischen pankreascysten. Deut. Zschr. f Chir., 80:
19-95, 1905. 8
Ransohoff, J.: Pancreatic cyst as a cause of
LESIO:\'B OF PANCREAS :\fIJ\JTCKT:\'G RE)[AL DI8E,'.SE
was the presenting 6.)'lll]Jtom, He felt that the hematuria wa:,; clne to pressure of thte cyst on the renal Yein. Following mar~upialization of the cyst rhere was no recurrence of the hematmia. Radiographic s/ud£es. Because of the intimate relationship of the tail of Hw pancreaR to the left kidney, any mass of this area of the pancreas could encrnach directly on the left urinary tract. In l l cases in this series, downward disJJlacement ,if the left kidney with m without rotation was noted by excretory urography. In two of these urnes (numbers 6 and 8) with a diagnosis of carcinoma of the pancreas, (fig. 6,:1) distortion ,,·as felt to be secondaiT to invasion of the kidney hy the tumor. However, as ilhrntrated in cases 1 and 7 (fig. 2,A and 5), apJJarent calyceal distortion can likewise be caused by a lesion extrinsic to the The most common finding in studie.~ of the upper gastrointestinal tract 1vas an anterior displacement of the stomach; this was noted in 7 cases. This finding, if present, is or :
'Wiese, H. W. and Larimore, J. W.
Roent~
g(c;uology of extra-alimentary r.umors. Amer. J Rocntgcnol., 27: 383--iO.Jc, HJ32.
Surgical exploration proYidecl Uie dehniiI 1·e diagnosis in all easPs. SU1\Ill1AR.Y
A series of 13 cases are present.eJ., that lesions of the pancreas may mimic le.~ions of the urinary tract. jJl patients in thi, series li,td symptom~ referable to the urinary tract,-,. A mas~ was palpable m the 13 cases, Laboratory ~tmlie" were limited value in the differentiation of Lhe le~ion.,. The combination of downward of the kidney on excretory urography, u.nd antnior displacement of the stomach on npJJer ga~tro intestinal radiography ,rn., seen in the of cases. The basis for the confusion in the clifferenfo1l diagnosis of pancreatic and renal lesions JS 1he int.irnate anatomical relationship of the and panc:rea., within the c,nity. _.\.ny space-occupying lesion of t.he paucrea,; can encroach directly on a kidney or urer,e,· a.nd present both ,c;ymptoms and radiographic: suggestive of a primary lesion oi' the tract. It is the intent of the authur~ t.u size, by means of these 13 cases, thaL lesions ol' the pancrea,, should be considered in th,, differential diagnosis of retroperitonea.J ma.s.,c·s the presence of signs and syrnµtom., uf renal disea~e. The authors are grateful to .Drs. D H. F. Hinn1an, Jr., R.. ()ppenhein1er and (). (;·rioH:'N for use of their cases.
HEFEHE)JCE GRAY, H.: Anatomy of the lluma.11 delphia. Lea & Febiger, 271,h (;d.,
Pliilnp. I:l09.
Vol. 93, No. 1 January 1965 Copyright © 1965 by The Williams & Wilkins Co.
Printed in U.S.A.
LESIONS OF THE PANCREAS MIMICKING RENAL DISEASE SUMNER MARSHALL, MAURICE LAPP
AND
JOHN W. SCHULTE
From the Division of Urology, Department of Surgery, University of California Medical Center, San Francisco, California
Because of the intimate anatomical relationship of the kidneys and pancreas within the retroperitoneal cavity, it is not uncommon for spaceoccupying lesions of the pancreas to encroach directly on the kidneys or ureters and to produce both symptoms and radiological changes suggestive of a primary lesion of the urinary tract. 1 - 5 The pancreas, like the kidneys, is essentially a retroperitoneal organ and is situated transversely across the posterior wall of the abdomen (fig. 1). Anteriorly and inferiorly, it is closely associated with the duodenum, transverse colon, and stomach. The posterior surface, being devoid of peritoneum, is in direct contact on the right with the inferior vena cava, the right renal vein, and Gerota's fascia of the right kidney. On the left, it traverses the aorta and left renal artery, and extends upward toward the spleen, crossing the upper part of the kidney. This intimate anatomical relationship of the pancreas to the urinary tract, especially to the left kidney, is adequate reason for tumors of the pancreas to mimic diseases of the urinary tract. A series of 13 cases of pancreatic tumors with renal symptoms will be presented here.
chills and fever. Radiographic studies suggested a primary renal lesion (fig. 2); serum amylase was elevated. At operation, a pseudocyst was found arising from the tail of the pancreas and lying above and separate from the kidney. Case 2. A pseudocyst of the tail of the pancreas was manifest clinically in a 23-year-old woman by a fullness in the left upper abdominal quadrant. Serum amylase was elevated. An excretory urogram prior to operation showed downward displacement and a vertical axis of the left kidney. Case 3. A 60-year-old man consulted his physician because of a 2-month history of nausea, vomiting, periumbilical pain and exertional dyspnea. A tender, fixed mass was palpable in the left upper abdominal quadrant. Radiographic studies showed downward displacement of the left kidney (fig. 3,A), anterior displacement of the stomach (fig. 3,B), and a left pleural effusion (fig. 3,C). Microscopic hematuria was present; serum amylase was elevated. Exploratory laparotomy revealed a pseudocyst of the pancreas in the left subdiaphragmatic area with direct extension of this mass to the left renal fossa. Case 4. A 46-year-old man with a 2-year history of intermittent episodes of left flank pain, nausea, and vomiting was found at operation to have a calcified cyst lying anterior to the kidney in continuity with the pancreas (fig. 4). Case 5. Carcinoma of the tail of the pancreas in a 74-year-old man was associated with anorexia, weakness, and left flank pain. Microscopic hematuria was present. Radiographic findings included depression of the left kidney, anterior displacement of the stomach, and a left pleural effusion. Case 6. A 63-year-old man who had experienced episodes of nausea, vomiting, and pain in the left flank for 3 months was noted to have microscopic hematuria. Excretory urography showed incomplete filling of the collecting system suggestive of a space-occupying lesion of the upper pole of the left kidney. At operation this was found to be a large infiltrating tumor arising
CASE REPORTS
Case 1. A 28-year-old man had a 6-year history of episodes of left flank pain, nausea, vomiting, Accepted for publication June 4, 1964. Read at annual meeting of Western Section, American Urological Association, Inc., Coronado, California, February 17-20, 1964. 1 Abeshouse, B. S.: Collective review. The differential diagnosis of pancreatic and renal disease, with particular emphasis on differentiating pancreatic cysts from renal cysts. Int. Abst. Surg., 96: 1-28, 1953. 2 Ormond, J. K., Wadsworth, G. H. and Morley, H. V.: Pancreatic lesions confusing urologic diagnosis. Report of 3 cases. J. Urol., 48: 650-657, 1942. 3 Stone, E. P.: Pancreatic cysts simulating renal disease. J. Urol., 62: 104-117, 1949. 4 Surmonte, J. A., Miller, J. M., Ginsberg, M. and Meisel, H. J.: Pseudocyst of the pancreas simulating disease of the kidney. J. Urol., 81: 606-608, 1959. 5 Thompson, G. J. and Culp, 0. S.: Perplexing cystic masses near the kidney. J. Urol., 89: 370376, 1963. 41
42
MARSHALL, LAPP AND SCHULTE
from the tail of the pancreas with direct extension to the spleen, left adrenal, and upper pole of the left kidney. Case 7. A 55-year-old man entered the hospital with a 3-month history of abdominal pain in the left upper quadrant, vomiting, and a 20-
Fm. 1. Relationship of pancreas to other organs. Note its intimate anatomical relationship to left kidney.
pound weight loss. He was subsequently found to have carcinoma of the tail of the pancreas which, by excretory urography, had been interpreted as a space-occupying lesion of the lower pole of the left kidney (fi@:. 5). Case 8. Carcinoma of the body and tail of the pancreas was found in a 65-year-old man after he had experienced episodes of anorexia and left flank pain for 7 months. Palpation of a firm mass in the left upper abdominal quadrant had caused radiation of pain to the left inguinal region. An excretory urogram showed depression and a shift of the axis of the left kidney (fig. 6,A), which had not been present on urograms obtained 2 months earlier (fig. 6,B). Case 9. A 71-year-old man had a 6-week history of intermittent episodes of nausea, vomiting, and pain in the left upper abdominal quadrant. Radiographic studies showed lateral and downward displacement of the left kidney and anterior displacement of the stomach. At operation an
FIG. 2. Case 1. A, excretory urogram and B, aortogram delineate mass in region of upper pole of left kidney which proved at surgery to be pseudocyst of pancreas. Note distorted calyceal system on urogram and abnormal contour of kidney on nephrogram phase of aortogram.
Fm. 3. Case 3. Pseudocyst of pancreas caused, A, considerable depression of left kidney; B, anterior displacement of stomach; and C, left pleural effusion.
LESIONS OF PANCREAS MIMICKING RENAL DISEASE
adenocarcinoma of the body and tail of the pancreas was found, with direct extension of the tumor to the stomach, transverse colon, spleen, and left adrenal gland. Case 10. A 47-year-old man entered the hospital after a 5-year history of recurrent episodes
Fm. 4. Case 4. Calcified cyst of pancreas appears on excretory urography to be of renal origin.
Fm. 5. Case 7. Carcinoma of tail of pancreas gives appearance on excretory urography of mass of lower pole of left kidney.
43
of nausea, vomiting, and epigastric pain with radiation to the back. Nineteen years previously the patient had had an unexplained episode of total gross hematuria. Excretory urography showed downward displacement of the left kidney which was found at exploratory laparotomy to be caused by carcinoma of the tail of the pancreas. Case 11. A tender, smooth mass measuring 10 cm. in diameter was palpable in a 62-year-old white man who had experienced malaise, anorexia, and a 20-pound weight loss over the previous 6 months. This mass, which was found at operation to be carcinoma of the body and tail of the pancreas, caused a marked depression and exaggerated oblique axis of the left kidney (fig. 7). Case 12. A 31-year-old man had experienced a sensation of abdominal fullness with minimal discomfort over a 4-month period. Pertinent physical findings included a hard, smooth mass in the left upper abdominal quadrant which descended with respiration, and a left varicocele. The left kidney appeared to be markedly displaced when seen on an excretory urogram. Exploratory laparotomy revealed the body and tail of the pancreas to be completely replaced by a tumor. Case 13. Carcinoma of the body and tail of the pancreas was found at operation in a 67-year-old woman who had noticed epigastric pain radiating to the back and a 15-pound loss in weight over the previous year. This palpable mass had been radiographically seen to have caused anterior displacement of the stomach and depression of the left kidney.
Fm. 6. Case 8. A, excretory urogram shows downward and lateral displacement of left kidney by an anaplastic carcinoma of tail of pancreas. B, excretory urogram taken 2 months earlier was felt to be within normal limits.
44
MARSHALL, LAPP AND SCHULTE
Fm. 7. Case 10. Infiltrating carcinoma of pancreas occupying much of left retroperitoneum is seen to markedly depress left kidney, as well as to exaggerate its oblique axis. 1. Summary of pertinent clinical, laboratory and radiographic findings in thirteen cases of pancreatic lesions mimicking urological disease
TABLE
Pertinent Findings
History Gastrointestinal symptoms Urogenital symptoms Physical examination Palpable mass Movable mass Diagnosis after surgery Carcinoma of the pancreas Pancreatic cyst Laboratory data Elevated serum amylase (all cysts) Hematuria (cyst and carcinoma) Radiography I.V.P.: Downward displacement of kidney Calyceal distortion G. I. series: Anterior displacement of stomach
No. Cases
% Cases
13
100%
11
85
8 2
62
9 4
69 31
3
23
3
23
11
85
4 7
54
25
31
DISCUSSION
Table 1 summarizes pertinent clinical, laboratory and radiographic findings in our series. History. All patients in this series had symptoms referable to the gastrointestinal tract, the most common of which were anorexia, nausea, vomiting and abdominal discomfort. Eleven of
these patients had associated complaints of flank pain, suggestive of renal involvement. The symptoms caused by direct encroachment on the kidneys by these lesions are usually indistinguishable from those caused by any irritation of the urinary tract. Because of the common autonomic and sensory innervations of the gastrointestinal and urinary systems, reno-intestinal reflexes are set off by such irritation. Afferent stimuli from the renal capsule or musculature of the pelvis may, by reflex action, cause changes in the tone of the smooth rn.uscles of the enteric tract, with a resultant clinical picture of gastrointestinal disease. 6 Physical examination. Masses were palpable in the left upper quadrant of the abdomen in eight of the 13 cases. Only two of these masses were mobile. Abeshouse1 believes that enlargements of the kidney are palpable and often ballotable in the flank and lumbar areas, whereas pancreatic lesions are less likely to be palpable in these areas. However, most of the lesions in our series involved the tail of the pancreas, which overlies the middle and upper half of the left kidney (fig. 1), thereby presenting themselves frequently in the left upper quadrant of the abdomen and flank. Laboratory tests. Since the serum amylase may be elevated in inflammatory lesions of the pancreas (cases 1, 2, 3), it could aid in the differentiation of pancreatic cysts and renal masses. No such elevation in serum amylase was seen in any of the cases of carcinoma of the pancreas. Microscopic hematuria was present in three of our cases, one with a pseudocyst (case 3) and two with carcinoma (cases 5 and 6). This finding has been noted previously in the literature1 - 3 , 7 and is felt to be secondary to toxic or inflammatory changes in the kidney, independent of or resulting from the pancreatic disease. In cases 3 and 5, there was a significant inflammatory reaction in the left subdiaphragmatic area with the presence of a left pleural effusion in both patients. Direct infiltration of tumor could likewise account for the hematuria (case 6). Ransohoff8 reported a case in which gross hematuria 6 Smith, D. R.: Gastrointestinal symptoms of genitourinary origin. Gastroenterology, 20: 119-
128, 1952.
7 Honigmann, F.: Zur Kenntnis der traumatischen pankreascysten. Deut. Zschr. f Chir., 80:
19-95, 1905. 8
Ransohoff, J.: Pancreatic cyst as a cause of
LESIO:\'B OF PANCREAS :\fIJ\JTCKT:\'G RE)[AL DI8E,'.SE
was the presenting 6.)'lll]Jtom, He felt that the hematuria wa:,; clne to pressure of thte cyst on the renal Yein. Following mar~upialization of the cyst rhere was no recurrence of the hematmia. Radiographic s/ud£es. Because of the intimate relationship of the tail of Hw pancreaR to the left kidney, any mass of this area of the pancreas could encrnach directly on the left urinary tract. In l l cases in this series, downward disJJlacement ,if the left kidney with m without rotation was noted by excretory urography. In two of these urnes (numbers 6 and 8) with a diagnosis of carcinoma of the pancreas, (fig. 6,:1) distortion ,,·as felt to be secondaiT to invasion of the kidney hy the tumor. However, as ilhrntrated in cases 1 and 7 (fig. 2,A and 5), apJJarent calyceal distortion can likewise be caused by a lesion extrinsic to the The most common finding in studie.~ of the upper gastrointestinal tract 1vas an anterior displacement of the stomach; this was noted in 7 cases. This finding, if present, is or :
'Wiese, H. W. and Larimore, J. W.
Roent~
g(c;uology of extra-alimentary r.umors. Amer. J Rocntgcnol., 27: 383--iO.Jc, HJ32.
Surgical exploration proYidecl Uie dehniiI 1·e diagnosis in all easPs. SU1\Ill1AR.Y
A series of 13 cases are present.eJ., that lesions of the pancreas may mimic le.~ions of the urinary tract. jJl patients in thi, series li,td symptom~ referable to the urinary tract,-,. A mas~ was palpable m the 13 cases, Laboratory ~tmlie" were limited value in the differentiation of Lhe le~ion.,. The combination of downward of the kidney on excretory urography, u.nd antnior displacement of the stomach on npJJer ga~tro intestinal radiography ,rn., seen in the of cases. The basis for the confusion in the clifferenfo1l diagnosis of pancreatic and renal lesions JS 1he int.irnate anatomical relationship of the and panc:rea., within the c,nity. _.\.ny space-occupying lesion of t.he paucrea,; can encroach directly on a kidney or urer,e,· a.nd present both ,c;ymptoms and radiographic: suggestive of a primary lesion oi' the tract. It is the intent of the authur~ t.u size, by means of these 13 cases, thaL lesions ol' the pancrea,, should be considered in th,, differential diagnosis of retroperitonea.J ma.s.,c·s the presence of signs and syrnµtom., uf renal disea~e. The authors are grateful to .Drs. D H. F. Hinn1an, Jr., R.. ()ppenhein1er and (). (;·rioH:'N for use of their cases.
HEFEHE)JCE GRAY, H.: Anatomy of the lluma.11 delphia. Lea & Febiger, 271,h (;d.,
Pliilnp. I:l09.