0:01

So this is an overnight case which came to us

0:03

with pain abdomen, and then once we started seeing

0:07

this case, we saw lots of edema and fluid in the

0:12

right upper quadrant in the subhepatic space.

0:16

And perihepatic space in the Morrison pouch here.

0:20

And as we see this, lots of edema is there

0:22

involving the mesentery, but all of this is

0:25

situated in the paracolic gutter and goes

0:28

backwards in the retroperitoneum somewhere here.

0:32

So this is the location which

0:33

is where it is pointing out.

0:35

And then we see an underlying cystic structure

0:39

in the pancreas, which is possibly showing

0:42

some communication with the main pancreatic

0:43

duct, but duct itself is not dilated.

0:46

So this looks like it possibly

0:49

a side branch IPMN here.

0:51

The question is, what is this here?

0:53

Is this a perforated IPMN, which led to diffuse

0:58

mucin inside the peritoneum and retroperitoneum?

1:01

So let's go to the coronal

1:02

and see how it looks there.

1:03

So in the coronal, we can see lots of fluid

1:05

surrounding the surface of the liver here.

1:09

Under surface of the liver, paracolic gutter,

1:12

retroperitoneum and the same thing if we go

1:14

backwards and look where it points out, so we can

1:18

see a limb or extension of this collection towards

1:21

the pancreas that becomes triangular here that

1:25

shows a communication, a linear communication with

1:30

the same lesion which we have seen in the axial.

1:32

So this is a side branch IPMN,

1:35

which is communicating with the main duct

1:39

here. And that is likely perforated.

1:42

So that was our diagnosis based on these images.

1:45

And we called it spontaneous rupture of

1:48

IPMN is very, very rare, but can happen.

1:50

That's in this particular case, they can

1:52

just rupture because they have become so big,

1:54

they cannot sustain the pressure from the

1:57

content inside and the wall just ruptures.

2:00

So it is a very rare presentation.

2:03

So after this, the surgeon actually took

2:04

this patient to the OR and did ERCP.

2:08

And this is how the ERCP looks.

2:10

We can see the pancreatic duct here.

2:14

As we fill this more, we can start seeing some

2:16

of the extravasation of the contrast, which

2:20

becomes even more prominent with the time.

2:23

So this was the IPMN which was ruptured and

2:27

what they did basically they placed a stent

2:29

along with this, and that was healed by itself.

2:35

So perforated IPMNs are rare,

2:37

but that can happen, and the treatment of

2:39

choice is placing a stent across that.