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Pancreatic Pseudocysts

Updated : January 23, 2024





Background

A pancreatic pseudocyst is a fluid-filled sac that develops in or around the pancreas. It is a complication often associated with acute or chronic pancreatitisA true cyst is characterized by a confined accumulation of fluid enclosed within an epithelial-lined capsule.

In contrast, a pseudocyst is so named due to its non-epithelialized wall composed of fibrous and granulation tissue. Specifically, a pancreatic pseudocyst refers to a contained reservoir of uniform fluid with minimal or no necrotic tissue.

Typically well-defined, these pseudocysts are situated outside the pancreas, frequently in the lesser sac. They commonly arise as a complication of chronic pancreatitis and, less frequently, from acute pancreatitis. 

Epidemiology

Pancreatic pseudocysts are a known complication of acute pancreatitis. The incidence of pseudocyst formation in the setting of acute pancreatitis varies but is estimated to be around 5–15%. Pseudocysts are more commonly associated with chronic pancreatitis. The prevalence of pancreatic pseudocysts in chronic pancreatitis ranges from 20% to 40%.

Severe or recurrent pancreatitis increases the risk of pseudocyst development. Pancreatic pseudocysts can occur at any age, but they are more commonly seen in adults. There may be a slight male predominance in the incidence of pancreatic pseudocysts. 

Anatomy

Pathophysiology

The most common cause of pancreatic pseudocysts is pancreatitis. Pancreatitis, whether acute or chronic, involves inflammation of the pancreas. During this inflammatory process, the pancreatic ducts can become damaged or disrupted. Trauma to the pancreas, such as abdominal injuries or surgical procedures involving the pancreas, can also lead to ductal injuries.

In the presence of pancreatic duct injury, pancreatic enzymes and fluid can leak out of the ducts and into the surrounding tissues. The leaked pancreatic fluid may accumulate in the retroperitoneal space, often forming a cavity or pseudocyst. The leaked pancreatic fluid may become encapsulated by surrounding tissues, including the stomach, pancreas, omentum, colon, or other adjacent structures.

The encapsulation process involves the formation of a wall around the fluid collection, consisting of fibrous and granulation tissue. This wall is what distinguishes a pseudocyst from a true cyst, as it lacks an epithelial lining. Over a period of 4 to 6 weeks, the wall of the pseudocyst matures and becomes well-defined. During this time, the pseudocyst may evolve in size and shape. 

Etiology

  • Trauma: Injuries to the pancreas, whether due to abdominal trauma, surgical procedures involving the pancreas, or accidental trauma, can lead to disruptions in the pancreatic ducts. The extravasation of pancreatic fluid from these damaged ducts may give rise to pseudocysts. 
  • Pancreatic Neoplasms: Tumors or neoplastic growths in the pancreas can lead to the obstruction or destruction of pancreatic ducts, increasing the risk of pseudocyst formation. 
  • Acute Pancreatitis: Pancreatic pseudocysts commonly arise as a complication of acute pancreatitis. In acute pancreatitis, there is a sudden inflammation of the pancreas, often triggered by factors such as gallstones, alcohol consumption, infections, or certain medications. The inflammation can lead to damage or disruption of the pancreatic ducts, causing leakage of pancreatic fluid and subsequent pseudocyst formation. 
  • Chronic Pancreatitis: Persistent inflammation of the pancreas in chronic pancreatitis can also result in pancreatic ductal injury and pseudocyst development. 

 

 

Genetics

Prognostic Factors

The prognosis of pancreatic pseudocysts varies depending on several factors, including the size of the pseudocyst, the presence of symptoms, and the underlying cause. In many cases, pancreatic pseudocysts resolve on their own, but complications can arise, impacting the overall prognosis. 

Clinical History

Pancreatic pseudocysts often develop as a complication of pancreatitis, either acute or chronic. A patient’s history may include episodes of abdominal pain, which could be related to the underlying pancreatic disease. A history of trauma to the pancreas or previous pancreatic surgery can contribute to the development of pancreatic pseudocysts. Excessive alcohol consumption is a known risk factor for pancreatitis, which, in turn, can lead to pseudocyst formation.

A history of chronic alcohol use may be relevant. Previous symptoms of pancreatitis, such as abdominal pain, nausea, vomiting, and changes in bowel habits, may be reported. The onset of symptoms can vary. In acute pancreatitis, symptoms may develop suddenly, while chronic pancreatitis may have a more insidious onset. The duration of symptoms depends on various factors, including the size of the pseudocyst, the presence of complications, and the underlying cause.

Some pseudocysts may resolve spontaneously, while others may persist or recur. In cases of chronic pancreatitis, the development of pancreatic pseudocysts may be associated with a prolonged course of underlying pancreatic disease. The onset of complications, such as infection or bleeding within the pseudocyst, can lead to a sudden exacerbation of symptoms and may prompt urgent medical attention. 

Physical Examination

Abdominal Tenderness: 

  • Palpation of the upper abdomen may reveal tenderness, especially in the area where the pancreas is located. Tenderness could be more localized if the pseudocyst is near the surface. 

Jaundice: 

  • If the pseudocyst compresses the common bile duct, it may result in jaundice.  

Bowel Sounds: 

  • Changes in bowel sounds may be noted. For example, there may be decreased bowel sounds if the pseudocyst is causing compression on the intestines. 

Hepatomegaly or Splenomegaly: 

  • Enlargement of the liver or spleen may be observed if the pseudocyst is causing pressure on these organs. 

Cullen’s Sign or Grey Turner’s Sign: 

  • These are rare but potential signs of complications. Cullen’s sign refers to periumbilical ecchymosis (bruising around the belly button), and Grey Turner’s sign is ecchymosis on the flanks. These signs may indicate bleeding within or around the pancreas. 

 

Age group

Associated comorbidity

Associated activity

Acuity of presentation

Differential Diagnoses

Pancreatic Abscess 

Pancreatic Cystic Neoplasms 

Pancreatic Necrosis 

Peptic Ulcer Disease 

Gastric Cancer 

Pancreatic Pseudoaneurysm 

 

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

Medical Management: 

Pain management with analgesics, anti-inflammatory medications, and sometimes, proton pump inhibitors (PPIs) for gastric acid suppression. 

Endoscopic Drainage: 

Transpapillary Drainage (TPD): 

Utilizing endoscopic retrograde cholangiopancreatography (ERCP), a stent is placed through the pancreatic duct into the pseudocyst for drainage. 

Transmural Drainage (TSM): 

Using endoscopic ultrasound (EUS) guidance, a puncture is made through the stomach or duodenal wall into the pseudocyst, followed by the placement of stents for drainage. 

Indications for Surgical Drainage 

Recurrent pseudocysts, uncertainty about the origin, concerns for malignancy, difficult endoscopic access, or the need for a wider stoma for drainage. 

Combination Therapies: 

In some cases, a combination of endoscopic and surgical approaches may be employed for optimal management. 

Considerations for Malignancy: 

Clinical features raising concerns for malignancy (weight loss, palpable mass, multilocular pseudocysts, thick walls, elevated CEA levels) may prompt a more aggressive approach. 

Monitoring and Follow-up: 

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

Nutritional Support: 

Nutritional support may be necessary, especially if there are challenges with food intake due to symptoms or complication. 

 

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

Lifestyle Modifications

A low-fat diet may be recommended, as dietary fat can stimulate the pancreas to release digestive enzymes. For individuals with pancreatic pseudocysts or chronic pancreatitis, reducing fat intake can help alleviate symptoms and decrease the workload on the pancreas.

Consuming smaller, more frequent meals throughout the day can be beneficial. This approach may reduce the demand on the pancreas and minimize the stimulation of pancreatic enzyme secretion. For individuals with a history of alcohol-related pancreatitis, avoiding alcohol is crucial.

Alcohol can contribute to inflammation of the pancreas and exacerbate symptoms. For individuals who smoke, quitting smoking is strongly advised. Smoking is a risk factor for pancreatic diseases, and cessation can contribute to overall health and well-being. 

Role of Analgesic for pain relief

Acetaminophen 

Acetaminophen is often considered a safer option for pain relief in individuals with pancreatic pseudocysts. It is less likely to irritate the gastrointestinal tract compared to NSAIDs. However, it is crucial to avoid exceeding recommended doses to prevent liver damage. 

Ibuprofen: 

Ibuprofen is generally not the first-line choice for managing pain associated with pancreatic pseudocysts. This is because NSAIDs, including ibuprofen, can irritate the gastrointestinal tract and potentially worsen symptoms in individuals with pancreatic issues. 

The primary concern with NSAIDs is their potential to cause gastric irritation, increase the risk of gastrointestinal bleeding, and exacerbate pancreatic inflammation.

Given that pancreatic pseudocysts are often associated with pancreatitis or pancreatic ductal injuries, healthcare providers typically exercise caution when prescribing NSAIDs. 

 

Role of Opioid Analgesics

Oxycodone 

Oxycodone is prescribed for the treatment of moderate to severe pain, making it a effective option for managing the intense pain often associated with pancreatic pseudocysts. Oxycodone is available in various formulations, including immediate-release and extended-release forms.

The choice of formulation depends on the duration and intensity of pain, with immediate-release formulations offering rapid relief and extended-release formulations providing a more sustained effect over time.

Oxycodone may be prescribed alone or in combination with non-opioid analgesics, such as acetaminophen. Combining medications allows for a synergistic approach to pain management, potentially achieving better pain control with lower doses of opioids. 

 

Role of Anti-emetics

Ondansetron 

Ondansetron is a commonly prescribed antiemetic that works by blocking serotonin, a neurotransmitter involved in nausea and vomiting. It is often used to control nausea associated with pancreatic pseudocysts and can be administered orally or intravenously.  

Metoclopramide: 

Metoclopramide is often prescribed to manage nausea and vomiting, which can be common symptoms associated with the condition. It is beneficial when these symptoms are related to delayed gastric emptying caused by the presence of the pseudocyst or underlying pancreatic issues. 

 

Intervention with Endoscopic drainage

Endoscopic drainage is a minimally invasive procedure used in the management of pancreatic pseudocysts. It involves the use of endoscopy to create a drainage pathway for the pseudocyst, allowing its contents to be diverted into the gastrointestinal tract.

This approach is favored over traditional surgical methods due to its reduced invasiveness and associated benefits.

There are two main techniques used in endoscopic drainage: transpapillary drainage (TPD) via 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), plays a crucial role in the management of pancreatic pseudocysts.

This technique involves the placement of a stent through the pancreatic duct to create a pathway for the drainage of the pseudocyst into the gastrointestinal tract.

This technique is particularly beneficial when pancreatic pseudocysts result from disruptions or leaks in the pancreatic duct, allowing the drainage of pancreatic fluid through the natural ductal route.

When the pseudocyst is situated too far from the gastrointestinal lumen, making direct transmural drainage challenging, transpapillary drainage becomes a preferred alternative.

Transpapillary drainage has reported success rates ranging from 81% to 94%. Some studies have suggested that while transpapillary drainage can be adequate, there may be comparable outcomes with other techniques, such as EUS-guided transmural drainage. 

Intervention with Transmural Drainage

Transmural drainage is indicated when the anatomy of the pancreatic duct is disrupted, leading to the formation of a pseudocyst. This disruption can occur due to trauma, inflammation, or other pancreatic diseases.

When there are complications such as stricture formation along the pancreatic duct, transmural drainage provides an alternative route for draining the pseudocyst. Endoscopic ultrasound (EU) allows for detailed imaging, even in cases where the pseudocyst is not visibly protruding.

It helps in identifying non-bulging pseudocysts and those located in challenging anatomical positions. Studies comparing EUS-guided transmural drainage with non-EUS-guided approaches have shown higher technical success rates with EUS (~95% versus 59%).

As the trend in managing pancreatic pseudocysts moves towards less invasive techniques, transmural drainage, particularly EUS-guided drainage, is gaining popularity. 

Surgical Intervention

Surgical drainage may be considered when pseudocysts recur despite previous interventions, including endoscopic drainage. When the origin of the pseudocyst is uncertain or when there are diagnostic challenges, surgical drainage may be pursued for a more comprehensive investigation.

Clinical features that raise 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 the consideration of surgical drainage.

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

A systematic review found that laparoscopic drainage is associated with 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 in cases where the pseudocyst is extensive or has complex features. 

Management of Pancreatic Pseudocyst due to acute pancreatitis

The occurrence of spontaneous resolution in pseudocysts is frequent, particularly in cases following an episode of acute pancreatitis. As stable pseudocysts that exhibit no enlargement seldom induce symptoms, the preferred approach for managing uncomplicated pseudocysts is conservative.

This involves the use of analgesics and antiemetics as necessary, coupled with adherence to a low-fat diet. Patients in such scenarios typically undergo periodic imaging for timely identification in the event of pseudocyst enlargement or the emergence of complications. 

Management of Pancreatic Pseudocyst due to chronic pancreatitis

Pseudocysts arising as complications of chronic pancreatitis seldom undergo spontaneous resolution. Factors associated with a lower likelihood of spontaneous resolution encompass the presence of multiple cysts, cysts situated in close proximity to the pancreas’s tail, concurrent existence of other local anatomical complications like strictures or calcifications in the pancreatic ducts, and a progressive increase in cyst size.

Urgent intervention may become imperative if patients exhibit signs of peritonitis, infection, bleeding, or gastric outlet obstruction. Indicators of potential complications include a sudden exacerbation of abdominal pain, chills, persistent nausea, reduced oral intake, fevers, or hypotension. 

Medication

Media Gallary

Pancreatic Pseudocysts

Updated : January 23, 2024




A pancreatic pseudocyst is a fluid-filled sac that develops in or around the pancreas. It is a complication often associated with acute or chronic pancreatitisA true cyst is characterized by a confined accumulation of fluid enclosed within an epithelial-lined capsule.

In contrast, a pseudocyst is so named due to its non-epithelialized wall composed of fibrous and granulation tissue. Specifically, a pancreatic pseudocyst refers to a contained reservoir of uniform fluid with minimal or no necrotic tissue.

Typically well-defined, these pseudocysts are situated outside the pancreas, frequently in the lesser sac. They commonly arise as a complication of chronic pancreatitis and, less frequently, from acute pancreatitis. 

Pancreatic pseudocysts are a known complication of acute pancreatitis. The incidence of pseudocyst formation in the setting of acute pancreatitis varies but is estimated to be around 5–15%. Pseudocysts are more commonly associated with chronic pancreatitis. The prevalence of pancreatic pseudocysts in chronic pancreatitis ranges from 20% to 40%.

Severe or recurrent pancreatitis increases the risk of pseudocyst development. Pancreatic pseudocysts can occur at any age, but they are more commonly seen in adults. There may be a slight male predominance in the incidence of pancreatic pseudocysts. 

The most common cause of pancreatic pseudocysts is pancreatitis. Pancreatitis, whether acute or chronic, involves inflammation of the pancreas. During this inflammatory process, the pancreatic ducts can become damaged or disrupted. Trauma to the pancreas, such as abdominal injuries or surgical procedures involving the pancreas, can also lead to ductal injuries.

In the presence of pancreatic duct injury, pancreatic enzymes and fluid can leak out of the ducts and into the surrounding tissues. The leaked pancreatic fluid may accumulate in the retroperitoneal space, often forming a cavity or pseudocyst. The leaked pancreatic fluid may become encapsulated by surrounding tissues, including the stomach, pancreas, omentum, colon, or other adjacent structures.

The encapsulation process involves the formation of a wall around the fluid collection, consisting of fibrous and granulation tissue. This wall is what distinguishes a pseudocyst from a true cyst, as it lacks an epithelial lining. Over a period of 4 to 6 weeks, the wall of the pseudocyst matures and becomes well-defined. During this time, the pseudocyst may evolve in size and shape. 

  • Trauma: Injuries to the pancreas, whether due to abdominal trauma, surgical procedures involving the pancreas, or accidental trauma, can lead to disruptions in the pancreatic ducts. The extravasation of pancreatic fluid from these damaged ducts may give rise to pseudocysts. 
  • Pancreatic Neoplasms: Tumors or neoplastic growths in the pancreas can lead to the obstruction or destruction of pancreatic ducts, increasing the risk of pseudocyst formation. 
  • Acute Pancreatitis: Pancreatic pseudocysts commonly arise as a complication of acute pancreatitis. In acute pancreatitis, there is a sudden inflammation of the pancreas, often triggered by factors such as gallstones, alcohol consumption, infections, or certain medications. The inflammation can lead to damage or disruption of the pancreatic ducts, causing leakage of pancreatic fluid and subsequent pseudocyst formation. 
  • Chronic Pancreatitis: Persistent inflammation of the pancreas in chronic pancreatitis can also result in pancreatic ductal injury and pseudocyst development. 

 

 

The prognosis of pancreatic pseudocysts varies depending on several factors, including the size of the pseudocyst, the presence of symptoms, and the underlying cause. In many cases, pancreatic pseudocysts resolve on their own, but complications can arise, impacting the overall prognosis. 

Pancreatic pseudocysts often develop as a complication of pancreatitis, either acute or chronic. A patient’s history may include episodes of abdominal pain, which could be related to the underlying pancreatic disease. A history of trauma to the pancreas or previous pancreatic surgery can contribute to the development of pancreatic pseudocysts. Excessive alcohol consumption is a known risk factor for pancreatitis, which, in turn, can lead to pseudocyst formation.

A history of chronic alcohol use may be relevant. Previous symptoms of pancreatitis, such as abdominal pain, nausea, vomiting, and changes in bowel habits, may be reported. The onset of symptoms can vary. In acute pancreatitis, symptoms may develop suddenly, while chronic pancreatitis may have a more insidious onset. The duration of symptoms depends on various factors, including the size of the pseudocyst, the presence of complications, and the underlying cause.

Some pseudocysts may resolve spontaneously, while others may persist or recur. In cases of chronic pancreatitis, the development of pancreatic pseudocysts may be associated with a prolonged course of underlying pancreatic disease. The onset of complications, such as infection or bleeding within the pseudocyst, can lead to a sudden exacerbation of symptoms and may prompt urgent medical attention. 

Abdominal Tenderness: 

  • Palpation of the upper abdomen may reveal tenderness, especially in the area where the pancreas is located. Tenderness could be more localized if the pseudocyst is near the surface. 

Jaundice: 

  • If the pseudocyst compresses the common bile duct, it may result in jaundice.  

Bowel Sounds: 

  • Changes in bowel sounds may be noted. For example, there may be decreased bowel sounds if the pseudocyst is causing compression on the intestines. 

Hepatomegaly or Splenomegaly: 

  • Enlargement of the liver or spleen may be observed if the pseudocyst is causing pressure on these organs. 

Cullen’s Sign or Grey Turner’s Sign: 

  • These are rare but potential signs of complications. Cullen’s sign refers to periumbilical ecchymosis (bruising around the belly button), and Grey Turner’s sign is ecchymosis on the flanks. These signs may indicate bleeding within or around the pancreas. 

 

Pancreatic Abscess 

Pancreatic Cystic Neoplasms 

Pancreatic Necrosis 

Peptic Ulcer Disease 

Gastric Cancer 

Pancreatic Pseudoaneurysm