Case 2

This is an MRI of the abdomen; the salient abnormality is a large, well defined mass which appears to originate from the pancreatic tail as it is inseparable from pancreatic parenchyma. The mass shows highly heterogeneous signal intensity, which is mostly hypo-intense on T2. At the lower aspect of the mass, there are multiple distinct fluid-fluid levels showing T2 hyperintensity layered on T2 hypointense material in the dependent position- this is characteristic of layering of blood products. There is a hypo-intense rim forming a circle internal to the larger mass; within this circle there is an avidly enhancing lobular structure which matches the vascular blood pool on all post contrast phases. While a large component of the mass shows no enhancement, there are enhancing septations and a caudal component which is enhancing (this component is hyper-intense on the T2 images).

In segment IV of the liver, there is a cystic lesion with a thin, enhancing wall and a solid mural nodule which is also enhancing.

These findings represent a haematoma within a cystic pancreatic neoplasm, which contains a bleeding pseudoaneurysm within it. The cystic lesion in the liver likely represents metastasis from the pancreatic neoplasm.

The pancreatic mass likely represents a pancreatic neuro-endocrine tumour with cystic degeneration and internal haemorrhage.

The differential diagnosis includes mucinous cystic neoplasm with malignant transformation.

Since this is complicated by haemorrhage with an active pseudo-aneurysm, this constitutes an emergency. I would urgently contact the referring physician, and discuss urgent laparotomy vs. embolisation by interventional radiology.