A pancreatic pseudocyst is a fluid-filled sac that forms in or near the pancreas, often because of acute or chronic pancreatitis. Unlike a true cyst, which has an epithelial-lined capsule enclosing the fluid, a pseudocyst has a wall made of fibrous and granulation tissue. Specifically, a pancreatic pseudocyst contains uniform fluid with little to no necrotic tissue. These pseudocysts are usually well-defined and located outside the pancreas, often in the lesser sac. They are commonly associated with chronic pancreatitis and, less frequently, with acute pancreatitis.

Pancreatic pseudocysts are a recognized complication of acute pancreatitis, with an estimated incidence of 5-15%. They are more frequently associated with chronic pancreatitis, where the prevalence ranges from 20% to 40%. The risk of developing pseudocysts increases with severe or recurrent pancreatitis. While pancreatic pseudocysts can occur at any age, they are more commonly observed in adults, with a slight male predominance.

Pancreatitis, both acute and chronic, is the most common cause of pancreatic pseudocysts.

Inflammation of the pancreas during pancreatitis can damage or disrupt pancreatic ducts.

Trauma to the pancreas, such as from abdominal injuries or surgeries, can also cause ductal injuries.

Pancreatic duct injuries allow pancreatic enzymes and fluid to leak into surrounding tissues.

The leaked fluid can accumulate in the retroperitoneal space, forming a cavity or pseudocyst.

Surrounding tissues, such as the stomach, pancreas, omentum, and colon, may encapsulate the leaked fluid.

The encapsulation process creates a wall of fibrous and granulation tissue around the fluid collection.

This wall distinguishes a pseudocyst from a true cyst, as it lacks an epithelial lining.

Over 4 to 6 weeks, the wall of the pseudocyst matures and becomes well-defined.

During this period, the pseudocyst may change in size and shape.

Trauma: Injuries to the pancreas from abdominal trauma, surgical procedures, or accidental trauma can disrupt pancreatic ducts, leading to the leakage of pancreatic fluid and the formation of pseudocysts.

Pancreatic Neoplasms: Tumors or neoplastic growths in the pancreas can obstruct or destroy pancreatic ducts, increasing the risk of pseudocyst formation.

Acute Pancreatitis: Pancreatic pseudocysts often develop as a complication of acute pancreatitis, which involves sudden inflammation of the pancreas due to factors like gallstones, alcohol consumption, infections, or certain medications. This inflammation can damage pancreatic ducts, causing fluid leakage and pseudocyst formation.

Chronic Pancreatitis: Persistent inflammation in chronic pancreatitis can also lead to pancreatic ductal injury and the development of pseudocysts.

The outlook for pancreatic pseudocysts depends on various factors such as their size, associated symptoms, and the underlying cause. While many pseudocysts may resolve spontaneously, complications can occur, affecting the overall prognosis.

Pancreatic pseudocysts are often a complication of pancreatitis, whether acute or chronic. They can be linked to a history of abdominal pain, trauma, previous pancreatic surgery, or excessive alcohol consumption. Symptoms vary in onset and duration, depending on the pseudocyst’s size, complications, and underlying cause. While some pseudocysts resolve spontaneously, others may persist or recur, especially in chronic pancreatitis. Complications like infection or bleeding can lead to a sudden worsening of symptoms, necessitating urgent medical attention.

Age group:

Pancreatic pseudocysts can develop at any age, but they are most frequently seen in adults, usually between 30 and 50 years old. They often arise as a complication of pancreatitis, which is more common in adults. However, children can also develop pseudocysts, particularly after experiencing abdominal trauma.

Abdominal Tenderness

Jaundice

Bowel Sounds

Hepatomegaly or Splenomegaly

Cullen’s Sign or Grey Turner’s Sign

Chronic Pancreatitis

Acute Pancreatitis

Trauma

Cystic Fibrosis

Alcoholism

The presentation of pancreatic pseudocysts can vary in acuity. They may present acutely after an episode of acute pancreatitis or abdominal trauma, with sudden onset of abdominal pain, nausea, or vomiting. Alternatively, they can develop chronically over weeks to months, often with vague symptoms like discomfort or bloating. In some cases, pseudocysts may be asymptomatic and discovered incidentally during imaging for other conditions.

Medical Management:

Pain management with analgesics and anti-inflammatory medications.

Proton pump inhibitors (PPIs) for gastric acid suppression.

Endoscopic Drainage:

Transpapillary Drainage (TPD): Using ERCP, a stent is placed through the pancreatic duct into the pseudocyst.

Transmural Drainage (TSM): Using EUS guidance, a puncture is made through the stomach or duodenal wall into the pseudocyst, followed by stent placement.

Indications for Surgical Drainage:

Recurrent pseudocysts, uncertain origin, malignancy concerns, difficult endoscopic access, or need for a wider stoma.

Combination Therapies:

Sometimes, both endoscopic and surgical approaches are used for optimal management.

Considerations for Malignancy:

Clinical features like weight loss, palpable mass, multilocular pseudocysts, thick walls, or elevated CEA levels may require a more aggressive approach.

Monitoring and Follow-up:

Regular imaging (ultrasound, CT scans) to monitor pseudocyst size and resolution after interventions.

Nutritional Support:

Necessary if there are challenges with food intake due to symptoms or complications.

Medical Management:

Pain management with analgesics and anti-inflammatory medications.

Proton pump inhibitors (PPIs) for gastric acid suppression.

Endoscopic Drainage:

Transpapillary Drainage (TPD): Using ERCP, a stent is placed through the pancreatic duct into the pseudocyst.

Transmural Drainage (TSM): Using EUS guidance, a puncture is made through the stomach or duodenal wall into the pseudocyst, followed by stent placement.

Indications for Surgical Drainage:

Recurrent pseudocysts, uncertain origin, malignancy concerns, difficult endoscopic access, or need for a wider stoma.

Combination Therapies:

Sometimes, both endoscopic and surgical approaches are used for optimal management.

Considerations for Malignancy:

Clinical features like weight loss, palpable mass, multilocular pseudocysts, thick walls, or elevated CEA levels may require a more aggressive approach.

Monitoring and Follow-up:

Regular imaging (ultrasound, CT scans) to monitor pseudocyst size and resolution after interventions.

Nutritional Support:

Necessary if there are challenges with food intake due to symptoms or complications.

Gastroenterology

A low-fat diet is often recommended because dietary fat can prompt the pancreas to release digestive enzymes.

Reducing fat intake can help ease symptoms and lessen the pancreas’s workload for those with pancreatic pseudocysts or chronic pancreatitis.

Eating smaller, more frequent meals throughout the day can reduce the demand on the pancreas and minimize enzyme secretion.

Avoiding alcohol is crucial for individuals with a history of alcohol-related pancreatitis, as alcohol can inflame the pancreas and worsen symptoms.

Quitting smoking is strongly advised for those who smoke, as smoking is a risk factor for pancreatic diseases and stopping can improve overall health.

Gastroenterology

Acetaminophen: 

Acetaminophen is usually safer to use for pain relief in patients with pancreatic pseudocysts. It is less likely to cause irritation of the gastrointestinal tract than NSAIDs. It is, however, important to be careful not to exceed the recommended dosage to avoid liver injury.

Ibuprofen:

Ibuprofen is not usually the first choice for managing pain from pancreatic pseudocysts, as NSAIDs can irritate the gastrointestinal tract and worsen symptoms in individuals with pancreatic issues. They may cause gastric irritation, increase the risk of bleeding, and aggravate pancreatic inflammation, especially in cases of pancreatitis or pancreatic ductal injuries, so healthcare providers typically avoid prescribing them.

Gastroenterology

Oxycodone: 
Oxycodone is prescribed for moderate to severe pain, making it effective for managing the intense pain of pancreatic pseudocysts. It comes in immediate-release and extended-release forms, with the choice depending on pain duration and intensity. Immediate-release provides quick relief, while extended-release offers longer-lasting effects. Oxycodone can be used alone or combined with non-opioid painkillers like acetaminophen for better pain control with lower opioid doses.

Gastroenterology

Ondansetron: 

Ondansetron is a frequently prescribed antiemetic that blocks serotonin, a neurotransmitter that plays a role in nausea and vomiting.

It is usually prescribed to treat nausea related to pancreatic pseudocysts and can be taken orally or intravenously.

Metoclopramide:

Metoclopramide is usually given to treat nausea and vomiting, which are often usual symptoms related to the disease. It works when the symptoms are due to delayed gastric emptying secondary to the presence of the pseudocyst or due to underlying pancreatitis.

Gastroenterology

Endoscopic drainage 

Endoscopic drainage is a minimally invasive procedure for managing pancreatic pseudocysts. It uses endoscopy to create a drainage pathway, allowing the pseudocyst’s contents to be diverted into the gastrointestinal tract. This method is preferred over traditional surgery due to its reduced invasiveness and associated benefits. There are two main techniques for endoscopic drainage: transpapillary drainage (TPD) using endoscopic retrograde cholangiopancreatography (ERCP) and transmural drainage (TSM) through the stomach or duodenal wall.

Intervention with Transpapillary Drainage

Transpapillary drainage, often performed through endoscopic retrograde cholangiopancreatography (ERCP), is key in managing pancreatic pseudocysts. It involves placing a stent in the pancreatic duct to drain the pseudocyst into the gastrointestinal tract, especially when the pseudocyst is caused by duct disruptions or leaks. This method is preferred when direct transmural drainage is difficult. Success rates for transpapillary drainage range from 81% to 94%, with some studies suggesting similar outcomes with other techniques like EUS-guided transmural drainage.

Intervention with Transmural Drainage

Transmural drainage is used when the pancreatic duct is disrupted, often due to trauma, inflammation, or other pancreatic diseases, leading to a pseudocyst. It provides an alternative drainage route when complications like strictures occur. Endoscopic ultrasound (EUS) offers detailed imaging, even for non-bulging or hard-to-reach pseudocysts, and studies show higher success rates with EUS-guided transmural drainage (~95% vs. 59% for non-EUS methods). As less invasive techniques gain favor, EUS-guided transmural drainage is becoming more popular.

Gastroenterology

Surgical drainage may be considered for recurrent pseudocysts despite previous interventions, including endoscopic drainage.

When the origin of the pseudocyst is uncertain or diagnostic challenges arise, surgical drainage may be pursued for a more comprehensive investigation.

Clinical features raising concerns for malignancy, such as a palpable mass, weight loss, multilocular pseudocysts, thick walls, and elevated carcinoembryonic antigen (CEA) levels in pseudocyst fluid, may prompt surgical drainage.

Pseudocysts that are difficult to access endoscopically due to their location or anatomical factors may be more effectively managed with surgical drainage.

A systematic review found laparoscopic drainage to have a high success rate (98.3%), a low recurrence rate (2.5%), a mean hospital stay of 5.5 days, and a complication rate of less than 2%.

Surgical drainage may be chosen when a wider stoma for drainage is required, especially for extensive or complex pseudocysts.

Gastroenterology

Management of Pancreatic Pseudocyst due to acute pancreatitis

Spontaneous resolution of pseudocysts is common, especially after an episode of acute pancreatitis. Stable pseudocysts that do not enlarge rarely cause symptoms, so the preferred management for uncomplicated pseudocysts is conservative. This includes using analgesics and antiemetics as needed, along with following a low-fat diet. Patients in these cases typically undergo regular imaging to detect any enlargement of the pseudocyst or the development of complications.

Management of Pancreatic Pseudocyst due to chronic pancreatitis

Pseudocysts from chronic pancreatitis rarely resolve on their own. Factors reducing the likelihood of spontaneous resolution include multiple cysts, cysts near the pancreas’s tail, other local complications like ductal strictures or calcifications, and increasing cyst size. Urgent intervention may be needed if signs of peritonitis, infection, bleeding, or gastric outlet obstruction occur. Indicators of complications include sudden worsening of abdominal pain, chills, persistent nausea, reduced oral intake, fevers, or hypotension.