What is the accumulation of blood in the abdominal cavity? A benign tumor is also dead!

Benign tumor is also fatal, when it is time to hand! There are several cases that often become the talk between clinicians, which can be described vividly to colleagues - "I tell you, there is a patient today, right..." One of them is that it is a "minor disease", but there are serious complications.it's amazing that the midfield has changed the direction of the plot.the condition of emergency patients today belongs to this kind of play.case introduction the patient, 78 years old, was admitted to hospital with "abdominal pain and hemorrhagic shock".previous history of pancreatic serous cystadenoma (SCA) and follow-up.with hypertension history.operation history: total thyroidectomy (toxic multinodular goiter) and cholecystectomy were performed.daily medication: levothyroxine, carvedilol, losartan + hydrochlorothiazide, olmesartan + amlodipine, alprazolam and chlorfluroxide ethyl ester.physical examination: abdominal tenderness, obvious muscle security.after diagnosis and treatment, the first blood test: hemoglobin (HB) was 91g / L, lactic acid was 7.71mmol/l.Blood Biochemistry: liver function was normal, amylase and lipase were within the reference value range, C-reactive protein was not high.after fluid resuscitation, Hb decreased to 54G / L in the second blood test.then 3 units of red blood cells and 2 units of plasma were transfused.after hemodynamic stability, emergency abdominal and pelvic CT showed a large amount of free fluid abdominal cavity hematocele, not old.mass in the body and tail of pancreas, 11.8 * 9.6cm, with thick and irregular interval in the mass.CT examination failed to identify the bleeding site.Figure 1: contrast enhanced CT images of abdominal cavity of patients. in order to further clarify the diagnosis, emergency DSA: bilateral iliac artery angiography found no signs of bleeding; abdominal trunk and superior mesenteric artery angiography found that the bleeding was from a mass with abundant blood supply. Yes, the serous cystadenoma in the tail of the pancreas almost killed the patient! The bleeding point was located near the center of the left side of the mass, which was the branch of splenic artery and superior mesenteric artery. The nutrient branches of splenic artery and superior mesenteric artery were embolized. the effect is instant! Figure 2: angiographic images: 7 days after embolization, the patient was discharged from hospital, and 2 weeks later, he was hospitalized for open surgery to remove the pancreatic mass and spleen. there were no complications after the two operations. Fig. 3: postoperative specimen Fig. 4: microscopic pathology: general manifestations: 15.5 × 15 × 8.5cm polycystic lesions, star shaped scar in the center, and clear liquid can be seen in the cyst after cutting the mass. microscopically, the diameter of the vesicles was less than 1cm, the wall of the septal sac was formed by cuboidal epithelial cells, PAS staining was positive, and the nucleus was round in the middle. no cytological and structural abnormalities were found, which accorded with the characteristics of microcapsule SCA. 6 months after operation, the patient recovered completely. Happy ending！ According to experience, the cause of hemorrhagic shock in this patient was the rupture of SCA vessel in the body and tail of pancreas. serous cystadenoma of the pancreas is a benign tumor of the pancreas. growth is slow, there are few obvious symptoms, and the rate of malignant transformation is low. The occurrence of serious complications and fatal cases is even more rare. the specific epidemiology, clinical features, diagnosis, etc. are not described here. taking this case of emergency treatment tonight, I would like to discuss with you the issue of "surgical intervention for benign tumors", mainly the choice of operation time. for pancreatic SCAs, Chinese experts pointed out that active surgical treatment should be performed when pancreatic SCAs > 6cm. even if the tumor is less than 6cm, active surgery should be considered if the following risk factors occur: related symptoms (such as abdominal pain, tumor compression, jaundice, vomiting, etc.) the tumor is located in the head of the pancreas, which can not completely rule out the malignant transformation and invasive performance, such as tumor invasion of surrounding tissues (blood vessels, peripancreatic lymph nodes, etc.) for pancreas without clinical symptoms, small tumor diameter and typical imaging characteristics Glandular SCAs, combined with clinical features and tumor markers, can be considered for monitoring and follow-up. nacif LS's suggestion is similar to the relevant contents of the guidelines in China: if the diameter of the tumor is larger than 6cm, and it is located in the head of pancreas, there is a high risk of malignant transformation, doctors should be more inclined to operate as soon as possible. in addition, there are also relatively radical views. For example, Tseng et al. Suggested that when the diameter of pancreatic SCAs is greater than 4cm, surgical resection should be considered even if the patient has no symptoms. according to their statistical data, the larger the SCAs volume is, the faster the growth rate is, and the greater the probability of symptoms and complications in the future. combined with domestic and foreign guidelines and suggestions, let's review the specific situation of today's emergency patients. Through medical history and imaging examination, we know that the maximum diameter of her pancreatic mass has reached more than 10 cm. according to the above domestic and foreign suggestions, it is obvious that there is already a surgical indication. if she had the tumor removed early, there might not have been a life-threatening bleeding. then why did the patient follow up without surgical resection? Is it suggested that the follow-up doctors should be too conservative to put the patients at risk? When we raise such doubts, we should also consider the risks brought about by the operation itself. According to the data, the probability of surgical complications of pancreatic SCAs is not low, especially the incidence of pancreatic fistula is high, and severe cases will also cause death. furthermore, the patient is old, has a history of hypertension, and is under multiple drug control, which means that her ability to tolerate the impact of surgery on cardiopulmonary function is low. this may be one of the considerations for the patient's attending physician to recommend follow-up. of course, this is just a guess. After all, we don't know the factors such as the interval of follow-up and the willingness of patients to operate. with the wide application of various medical auxiliary examinations, more and more asymptomatic cancer patients can be diagnosed. when we know that the nature of the tumor is benign, the timing of surgical intervention needs to be combined with a variety of factors - "specific analysis of specific problems". Reasonable and appropriate clinical decision-making may prevent patients from a near death experience. [J]. BMJ case Rep, 2020, 13: undefined. 2. Nacif ls, arantes RM, Martino Rb, et al. Pancreatic serous cy stadenoma:diagnostic and therapeutic management. [J] .Acta GastroenterolLatinoam，2016;46:382–5.3.Tseng JF, Warshaw AL, Sahani DV, et al. Serous cystadenoma of thepancreas: tumor growth rates and recommendations for treatment. [J].Ann Surg 2005; Chinese Journal of general surgery, 2016,31 (1): 75-78