Pancreatic Pseudocyst

A pseudocyst is a collection of amylase-rich fluid enclosed in a wall of fibrous or granulation tissue.

Typically arise following an attack of acute pancreatitis.

But can develop in chronic pancreatitis or after pancreatic trauma.

Most cysts communicate with the pancreatic duct.

Management Of Pancreatic Pseudocyst

Clinical features

  1. Usually occurs after an attack of acute pancreatitis (Usually after 4 weeks or more)
  2. Low grade fever
  3. Lump in the upper abdomen 
 

On examination

  1. Slight rise of temperature
  2. Mild jaundice
  3. Palpable mass in the epigastric region 
  4. Tenderness present in epigastric region 


Investigations

  1. Ultrasonography of hepatobiliary system and pancreas
  2. CT scan 


Treatment

  1. May resolve spontaneously 
  2. Percutaneous drainage 
    • Percutaneous drainage (Best avoided)
    • Percutaneous transgastric cystogastrostomy under imaging
      • Should be non neoplastic
      • Should not have any communication with the pancreatic duct
  3. Endoscopic 
    • EUS guided cystogastrostomy
  4. Surgery 
    • Cystogastrostomy
    • Cystojejunostomy 
 
Aspirated fluid is sent for further investigations to detect….

  • Carcinoembryonic antigen 
  • Amylase level
  • Cytology 


Indications Of Interventions Of A Pancreatic Pseudocyst
  1. Symptomatic
  2. Development of complications
  3. Suspicion of a tumor
 
 

Cysts that are less likely to resolve are….

  • Cysts with thick wall
  • Cysts that are more than 6 cm in diameter
  • Cysts that lasted for more than 12 weeks 
  • Cysts that arisen due to chronic pancreatitis  



Complications Of Pancreatic Pseudocyst

  • Infection 
    1. Abscess
    2. Systemic sepsis
  • Rupture 
    • Into the gut 
      1. Gastrointestinal bleeding
      2. Internal fistula
    • Into the peritoneum 
      1. Peritonitis
  • Enlargement
    • Pressure effects 
      1. Obstructive jaundice from biliary compression
      2. Bowel obstruction
    • Pain
  • Erosion into a vessel 
    1. Haemorrhage into the cyst
    2. Haemoperitoneum
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