Pancreatic Pseudocyst
Pancreatic Pseudocyst: Excerpt from The 5-Minute Pediatric Consult
Raman Sreedharan, MDDevendra I. Mehta, MD
Pancreatic Pseudocyst - BASICS
Pancreatic Pseudocyst - description
- Localized intrapancreatic or peripancreatic fluid collection that is rich in pancreatic enzymes but devoid of significant solid debris, enclosed by a wall of nonepithelialized granulation tissue
- Arises as a complication of acute or chronic pancreatitis
Pancreatic Pseudocyst - risk factors
Acute or chronic pancreatitis
Pancreatic Pseudocyst - pathophysiology
- Pancreatic pseudocysts develop shortly after an attack of acute pancreatitis or insidiously in chronic pancreatitis.
- Disruption in the pancreatic ductular system result in the extravasation of pancreatic enzymes evoking an inflammatory response.
- The inflammatory reaction leads to a fluid collection that is rich in pancreatic enzymes and is termed “acute pancreatic fluid collection” (PFC).
- If the duration of the fluid collection is >4 weeks, becomes localized (intrapancreatic or extrapancreatic), and develops a fibrin capsule, it is called as a “pseudopancreatic cyst.”
- The pseudocyst does not have a true epithelial lining.
- If there is communication between the pseudocyst and the pancreatic duct, the enzyme level in the fluid remains elevated, and if there is no communication, the enzyme level falls with time.
Pancreatic Pseudocyst - DIAGNOSIS
Pancreatic Pseudocyst - signs & symptoms
- Abdominal pain
- Abdominal mass
- Abdominal tenderness
- Nausea and vomiting
- Weight loss
- Jaundice
- Abdominal distention:
- In many situations, there are no clinical signs that are seen.
- Clinical signs may be secondary to complications:
- Jaundice in hepatobiliary obstruction
- Lower limb edema in compression of inferior vena cava
- Ascites in peritonitis
- Pleural effusion
Pancreatic Pseudocyst - history
Acute or chronic pancreatitis:
- Suspect pancreatic pseudocyst in patients recovering from acute pancreatitis or patient with chronic pancreatitis who has recurrent/persistent abdominal pain, a palpable abdominal mass, or persistently elevated pancreatic enzymes in blood.
Pancreatic Pseudocyst - tests
Pancreatic Pseudocyst - lab
Pancreatic enzyme levels:
- Persistently elevated enzymes in blood could be a clue, but is not an absolute indicator.
Pancreatic Pseudocyst - imaging
- CT scan:
- Reveals pseudopancreatic cyst and gauges size and relationship to adjacent organs
- Ultrasonography:
- Visualizes pancreatic pseudocysts
- Follow-up of cyst size
- Endoscopic ultrasonography:
- Evolving in the adult settings and will probably be used in the pediatric population soon
- Endoscopic retrograde cholangiopancreatography (ERCP):
- Used in some cases to delineate the pancreatic ductular system before drainage to distinguish ductal stenosis, stones, and other obstructions
Pancreatic Pseudocyst - differencial diagnosis
- Congenital/Genetic:
- Congenital cysts
- Polycystic disease
- Von Hippel-Lindau disease
- Cystic fibrosis
- Infections:
- Pancreatic abscess
- Echinococcal (hydatid) cyst
- Taenia solium cyst
- Tumor:
- Serous cystadenoma
- Mucinous cystadenoma
- Cystic islet cell tumors
- Teratoma
- Pancreatoblastoma
- Cystadenocarcinoma
- Franz tumor
- Angiomatous cystic neoplasms
- Lymphangiomas
- Hemangioendothelioma
- Miscellaneous:
- Splenic cyst
- Adrenal cyst
- Enterogenous cyst
- Duplication cysts
- Endometriosis
Pancreatic Pseudocyst - TREATMENT
Pancreatic Pseudocyst - general measures
- Medical management:
- Most cases resolve with supportive care.
- Follow up with ultrasound or CT scan to make sure there are no complications.
- >60% have complete resolution by the end of 1 year.
- Drainage:
- Indications: Infection, rupture with cardiopulmonary compromise, biliary and gastric outlet obstruction, persistent symptoms, rapid enlargement, failure of large pseudocysts (>6 cm) to shrink after 6 weeks
- Modalities:
- Percutaneous drainage (aspiration or catheter drainage) is done in cases where the pseudocyst has a less mature wall.
- Percutaneous aspiration has a high recurrence rate of 63% and failure rate of 54%.
- Continuous drainage has a recurrence rate of 8% and a failure rate of 19%.
- Endoscopic procedures are becoming the first-line drainage modality, as they are less invasive than surgery. Endoscopic procedures include transmural cystoenterostomies and transpapillary route procedures like stent placement for pseudocysts that communicate with the main pancreatic duct.
- Endoscopic procedures in experienced hands reported success rates of 82–89%, complication rates of 10–20% and recurrence rates of 6–18%.
Pancreatic Pseudocyst - surgery
- Reserved for failed endoscopic procedures, complicated pseudocysts, and multiple pseudocysts
- Includes internal drainage (cystogastrostomy, cystoduodenostomy, and Roux-en-Y cystojejunostomy), resection, and external drainage
- Success rate is 85–90%.
- Recurrence rate 0–17%
- Mortality rate between 3% and 5%
Pancreatic Pseudocyst - FOLLOW UP
Pancreatic Pseudocyst - prognosis
Majority of pseudocysts resolve without intervention.
Pancreatic Pseudocyst - complications
- Perforation/Rupture:
- Cardiopulmonary compromise secondary to pleural effusion and ascites
- Peritonitis and ascites, which can be fatal
- Hemorrhage:
- Erosions of vessels lining the cyst cause intracystic bleeding and rapid increase in the cyst size.
- Bleeding may occur directly into stomach, duodenum (clinically manifesting as gastrointestinal bleeding), or peritoneal cavity.
- Obstruction:
- Biliary obstruction: Jaundice
- Portal obstruction: Portal hypertension
- Gastric outlet obstruction
- Inferior vena cava obstruction: Peripheral edema
- Urinary obstruction
- Colonic obstruction
- Infection is rare in children compared to adults:
- High mortality rate for children and adults
- Management usually requires surgical drainage.
Pancreatic Pseudocyst - bibliography
- Law NM, Freeman ML. Emergency complications of acute and chronic pancreatitis. Gastroenterol Clin. 2002;32:1169–1194.
- Reber HA. Surgery for acute and chronic pancreatitis. Gastrointest Endosc. 2002;56(suppl):S246–S248.
- Vidyarthi G, Steinberg SE. Endoscopic management of pancreatic pseudocysts. Surg Clin North Am. 2001;81:405–410.
- Weckman L, Kylanpaa ML, et al. Endoscopic treatment of pancreatic pseudocysts. Surg Endosc. 2006;20(4):603–607.
Pancreatic Pseudocyst - CODES
Pancreatic Pseudocyst - icd9
577.2 Pancreatic pseudocyst
Pancreatic Pseudocyst - FAQ
- Q: How often does acute pancreatitis lead to pseudocyst formation?
- A: ~10% of cases of acute pancreatitis develop pseudocyst.
- Q: Can a pancreatic pseudocyst go unnoticed?
- A: Yes, as the natural history of the disease process is healing by itself
- Q: What mode of therapy has the least recurrence rate?
- A: Surgical excision
Book Source Details
- Book Title: The 5-Minute Pediatric Consult
- Author(s): M. William Schwartz MD; et al.
- Year of Publication: 2008
- Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.
More About Pancreatic Islet Cell Cancer
More Medical Textbooks Online about Pancreatic Islet Cell Cancer
Review other book chapters online related to Pancreatic Islet Cell Cancer:
Medical Books Excerpts
- Diabetes Mellitus
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
|
|
More About This Book:
Title: The 5-Minute Pediatric Consult
Authors: M. William Schwartz MD; et al.
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7577-9
|
|
» Next page: Pancreatitis (The 5-Minute Pediatric Consult)
Rate This Website
What do you think about the features of this website?
Take our user survey and have your say:
Website User Survey
Medical Tools & Articles:
Next articles:
Tools & Services:
Medical Articles:
Forums & Message Boards
- Ask or answer a question at the Boards:
