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Updated: Dec 15 2021

Pancreatic Pseudocyst

  • 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
    • 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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