Pancreatic Pseudocyst

• • 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

Epidemiology

• • 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

Symptoms and Signs

• • 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

Laboratory Findings

• • Elevated serum amylase

  • Leukocytosis

  • Elevated bilirubin levels reflect biliary obstruction

Imaging Findings

• • 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

• • 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

Rule Out

• • 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

• • Serum amylase

  • Serum bilirubin

  • CBC

  • Abdominal CT

  • ERCP if indicated

When to Admit

• • Severe symptoms

  • Infection

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

  • Drainage options:

  • -Internal (cystgastrostomy or jejunostomy)

    -External

    -Percutaneous (infected)

Surgery

Indications

• • All symptomatic pseudocysts

  • Cysts > 5 cm that have not resolved ...