Updated: 6/14/2019

Pancreatic Pseudocyst

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Snapshot
  • A 43-year-old woman presents to the clinic for complaints of abdominal discomfort for the past 3 weeks. He reports some dull, 3/10 pain around the epigastric region especially after he eats. His past medical history is significant for 1 episode of gallstone pancreatitis 5 weeks ago. A physical examination demonstrates an abdominal mass at the epigastric region.  

Introduction
  • Clinical definition
    • describes a circumscribed collection of fluid containing pancreatic enzymes, blood, and necrotic tissue occurring outside the pancreas
      • the capsule is a non-epithelialized wall consisting of fibrous, granulation tissue
      • usually develops within several weeks after the onset of pancreatitis 
  • Epidemiology
    • demographics
      • accounts for approximately 75% of all pancreatic masses
      • male predominance, which mirrors the demographic distrubtion seen in pancreatitis
  • Pathogenesis
    • most commonly occurs following acute pancreatitis and abdominal trauma but can also occur due to chronic pancreatitis
      • abdominal trauma is the more common cause in children
    • can also be single or multiple, though multiple cysts are more frequently seen in patients with alcoholism
    • the condition seems to stem from disruptions of the pancreatic duct
      • occurs due to pancreatitis and/or extravasation of enzymatic material
  • Associated conditions
    • acute pancreatitis
      • alcoholism
      • gallstone
    • chronic pancreatitis
    • abdominal trauma
Presentation
  • Symptoms 
    • abdominal pain  
      • usually with a history of pancreatitis
    • anorexia
    • indigestion
    • nausea
  • Physical exam
    • abdominal mass
    • tender abdomen
    • fever
    • scleral icterus
    • pleural effusion
    • peritoneal signs
      • if cyst rupture or infection
Studies
  • Diagnostic testing
    • diagnostic approach
      • diagnosis is primarily based on clinical presentation and patient history and confirmed via imaging
    • imaging
      • abdominal computed tomography (CT) with contrast 
        • preferred diagnostic test
        • positive findings include a well-circumscribed fluid collection that is typically extra-pancreatic with homogenous fluid density with no internal septae
      • magnetic resonance imaging (MRI)
        • more sensitive test compared to CT
        • allows for better differentiation between pancreatic pseudocyst and other diagnosis (e.g., pseudoaneurysm)
      • endoscopic ultrasound (EUS)
        • indicated in patients where the imaging findings or clinical setting is unclear/atypical
        • can assess for features suggestive of a cystic neoplasm (e.g., internal septations)
        • allows for treatment planning
    • studies
      • serum amylase and lipase
        • may be normal or elevated
      • serum bilirubin and liver function tests
        • may be elevated if there is involvement of the biliary tree
      • cystic fluid analysis
        • low levels of carcinoembryonic antigen (CEA) and CEA-125
        • low fluid viscosity
        • high amylase
Differential
  • Cystic neoplasm
    • differentiating factors
      • MRI can often differentiate between pseudocyst and cystic neoplasm; if the diagnosis is still uncertain, EUS and fine-needle aspiration of the fluid can be evaluated
      • cystic fluid analysis will demonstrate high CEA-125, high fluid viscosity, and low amylase
Treatment
  • Most pseudocysts resolve without interference and require only supportive care
  • First-line
    • observation with follow-up imaging every 3-6 weeks
    • supportive care
      • nasogastric feeding if needed for pain relief
      • proton pump inhibitor
      • octreotide to reduce pancreatic secretions
  • Second-line
    • drainage of the pseudocyst is indicated in patients who are symptomatic, have rapidly enlarging pseudocysts, or have complications (e.g., infection of the cyst)
    • endoscopic drainage
      • preferred method of drainage
      • complications include bleeding, performation, and secondary infection
    • percutaneous catheter drainage  
      • higher morbidity, longer hospital stays, and longer duration of indwelling drains compared to endoscopic drainage
  • Third-line
    • surgery
      • indicated in patients with infected pancreatic necrosis and symptomatic sterile necrosis
Complications
  • Bleeding/hemorrhage
    • erosion of the pseudocyst into a vessel
  • GI obstruction
  • Pseudocyst rupture
  • Peritonitis
 

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Questions (3)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M2.GI.4684) A 23-year-old male presents to his primary care physician for a follow-up after being discharged from the hospital following a motor vehicle accident a month ago. He was a restrained driver in a front end collision. He reports he has recovered well, but notes that he has experienced abdominal bloating, and can't eat as much as he used to. On physical exam, the patient's abdomen is moderately distended, with no fluid wave. Bowel sounds are normal, but the patient notes discomfort upon deep palpation, especially in the epigastric region. An abdominal CT is obtained and shown in Figure A. What is the best treatment for this patient? Review Topic

QID: 107356
FIGURES:
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Pancreaticoduodenectomy

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Cystogastrostomy

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Endoscopic retrograde cholangiopancreatography (ERCP)

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Cholecystectomy

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5

Roux-en-Y gastric bypass

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M2

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