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  • • Recent history of acute pancreatitis, pancreatic trauma, or known chronic pancreatitis

    • Epigastric mass and pain

    • Mild fever and leukocytosis

    • Persistent serum amylase elevation

    • Pancreatic cyst demonstrated by US or CT scan

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Epidemiology

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  • • Encapsulated collections of pancreatic secretions

    • -Arise following acute pancreatitis or from chronic ductal obstruction (chronic pancreatitis) or acute ductal disruption (trauma)

    • The walls of a pseudocyst are formed by inflammatory fibrosis of the peritoneal, mesenteric, and serosal membranes, which limits spread of the pancreatic juice as the lesion develops

    • Pseudocysts develop in about 2% of cases of acute pancreatitis

    • -The cysts are single in 85% of cases

    • Pseudocyst should be suspected when a patient with acute pancreatitis does not recover after 1 week of treatment or when, after improving for a time, symptoms return

    • Pseudocysts can contain collections of sterile or infected material

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Symptoms and Signs

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  • • Abdominal pain is most common

    • Fever

    • Weight loss

    • Jaundice, due to obstruction of the intrapancreatic segment of the bile duct

    • Palpable, tender mass in the epigastrium

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Laboratory Findings

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  • • Elevated serum amylase

    • Leukocytosis

    • Elevated bilirubin levels reflect biliary obstruction

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Imaging Findings

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  • CT scan

    • -Diagnostic study of choice

      -Size and shape of the cyst and its relationship to other viscera can be seen

      -A pancreatic duct obstruction may be found with chronic pancreatitis

      -A dilated common bile duct suggests biliary obstruction

    US: May be useful to follow changes in size of an acute pseudocyst already imaged by CT scans

    ERCP: Should be performed if there is obstruction or disruption of the pancreatic duct as these findings would require endoscopic or surgical treatment

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  • • With wide use of sensitive imaging studies in the diagnosis of pancreatic disease, small asymptomatic pseudocysts are often demonstrated

    • -The natural history of these subclinical lesions is benign

      -There is no indication for prophylactic surgical treatment

    • Pancreatic pseudocyst associated with ductal obstruction (chronic pancreatitis) or disruption (trauma) is unlikely to resolve without correction of the underlying defect

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Rule Out

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  • • Pancreatic abscess

    • Acute pancreatic phlegmon

    • Pancreatic adenocarcinoma

    • Pancreatic neoplastic cysts

    • -Account for about 5% of all cases of cystic pancreatic masses

      -May be indistinguishable preoperatively from pseudocyst

      -Cyst wall must be biopsied to exclude neoplasia

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  • • Serum amylase

    • Serum bilirubin

    • CBC

    • Abdominal CT

    • ERCP if indicated

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When to Admit

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  • • Severe symptoms

    • Infection

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  • • Asymptomatic cysts may be observed; 40% will resolve within 8-12 weeks

    • Drainage options:

    • -Internal (cystgastrostomy or jejunostomy)

      -External

      -Percutaneous (infected)

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Surgery

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Indications

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  • • All symptomatic pseudocysts

    • Cysts > 5 cm that have not resolved by 8-12 weeks after acute pancreatitis

    • Infected ...

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