Review Question - QID 216779

This patient with a history of pancreatitis who presents with epigastric abdominal pain, early satiety, tender abdomen, and an anechoic mass on ultrasound likely has a pancreatic pseudocyst. Pancreatic pseudocysts form due to the extravasation of enzymatic material into pancreatic tissue, causing disruption of the pancreatic duct.

Pancreatic pseudocyst is a late (>4 weeks) complication of acute pancreatitis that causes epigastric pain, mass symptoms (e.g., palpable mass), early satiety, dyspnea, and/or ascites. Release of pancreatic enzymes during pancreatitis and subsequent digestion of the pancreatic duct and tissue causes liquefactive necrosis that forms a cystic collection which is encapsulated by granulation tissue. Because pseudocysts are formed via the release of enzymes, they present with persistently elevated amylase levels. Pancreatic pseudocysts are diagnosed with imaging; ultrasound can be used, but CT is standard. Asymptomatic patients found to have a pseudocyst are treated with observation and bowel rest, while symptomatic patients are treated with endoscopic drainage.

Habashi and Draganov outline the pathophysiology, clinical presentation, evaluation, and management of pancreatic pseudocysts.

Incorrect Answers:
Answer 1: Autodigestion and calcification of peripancreatic fat are characteristic of fat necrosis during acute pancreatitis. Fat necrosis occurs due to release of lipase, which breaks down triglycerides to release fatty acids and enable saponification. However, acute pancreatitis presents with severe epigastric pain, elevated amylase/lipase levels, and diffusely enlarged pancreas on ultrasound, not chronic epigastric pain and a round, anechoic mass on ultrasound.

Answer 3: Hemorrhage involving pancreatic tissue describes hemorrhagic pancreatitis, which presents with symptoms similar to acute pancreatitis (severe epigastric pain, elevated amylase/lipase, and peripancreatic edema or hemorrhage on CT scan). It additionally causes a drop in hemoglobin and hematocrit levels, which is not present in this patient.

Answer 4: Intra-abdominal collection of bacteria and purulent material describes a pancreatic abscess. A pancreatic abscess is a complication of pancreatitis that appears as a fluid collection on ultrasound, and it typically occurs 5-10 days after acute pancreatitis. It also causes fever and leukocytosis, neither of which are present in this patient.

Answer 5: Primary malignancy of pancreatic duct describes pancreatic adenocarcinoma. Both pancreatic adenocarcinoma and pseudocyst present as an anechoic, cystic mass on ultrasound, but adenocarcinoma can present with epigastric pain, weight loss, obstructive jaundice, acholic stool, Courvoisier’s sign (painless, palpable gallbladder on exam), and migratory thrombophlebitis.

Bullet Summary:
Pancreatic pseudocyst is a late complication of pancreatitis caused by enzymatic disruption of the pancreatic duct that presents with abdominal pain, early satiety, and anechoic mass on ultrasound.