Updated: 10/22/2019

Pancreatic Pseudocysts

0%
Topic
Review Topic
0
0
N/A
N/A
Questions
1 1
0
0
0%
0%
Evidence
1 1
0
0
Topic
Snapshot
  • 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.
Introduction
  • 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
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 
  • 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 performed
      • 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
Topic Rating

Please rate topic.

Average 4.7 of 3 Ratings

 

Questions (1)

(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: Tested Concept

QID: 101125
FIGURES:
1

Palpable upper abdominal mass

58%

(115/199)

2

Dermatitis herpetiformis

6%

(12/199)

3

Acanthosis nigricans

17%

(34/199)

4

Splenomegaly

10%

(19/199)

5

Asterixis

8%

(16/199)

M 2 D

Select Answer to see Preferred Response

Evidence (1)
Topic COMMENTS (0)
Private Note