Updated: 12/15/2021

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
    • Associated conditions
      • acute pancreatitis
        • alcoholism
        • gallstone
      • chronic pancreatitis
      • abdominal trauma
  • Epidemiology
    • Demographics
      • accounts for approximately 75% of all pancreatic masses
      • male predominance, which mirrors the demographic distrubtion seen in pancreatitis
  • ETIOLOGY
    • 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
  • 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
  • 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
    • Diagnostic testing
      • diagnostic approach
        • diagnosis is primarily based on clinical presentation and patient history and confirmed via imaging
      • 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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(M2.GI.17.4684) 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?

QID: 107356
FIGURES:

Pancreaticoduodenectomy

56%

(5/9)

Cystogastrostomy

11%

(1/9)

Endoscopic retrograde cholangiopancreatography (ERCP)

22%

(2/9)

Cholecystectomy

0%

(0/9)

Roux-en-Y gastric bypass

11%

(1/9)

M 7 D

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