Updated: 10/22/2019

Pancreatic Pseudocysts

Review Topic
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  • A 42-year-old man with a history of alcohol abuse presents to the clinic with complaints of constant pain at the abdominal region. A physical examination demonstrates a 3-cm mass at the epigastric region. Further laboratory testing shows a persistently elevated serum and urine amylase.
  • Clinical definition
    • describes a circumscribed collection of fluid containing pancreatic enzymes, blood, and necrotic tissue occurring outside the pancreas
      • the capsule is a nonepithelialized 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
  • 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
  • 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
  • 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
  • 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 performed
      • cystic fluid analysis will demonstrate high CEA-125, high fluid viscosity, and low amylase
  • 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
  • Bleeding/hemorrhage
    • erosion of the pseudocyst into a vessel
  • GI obstruction
  • Pseudocyst rupture
  • Peritonitis

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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
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
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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(M1.GI.13.68) A 53-year-old male presents to the hospital with indigestion, steatorrhea, and worsening abdominal pain over several months. Figure A demonstrates a CT scan that shows a large, cystic region in the peritoneum. Which of the following physical findings would you most expect to be present in this patient: Review Topic | Tested Concept

QID: 101125

Palpable upper abdominal mass




Dermatitis herpetiformis




Acanthosis nigricans











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