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Pancreatic Pseudocyst

Pancreatic pseudocyst is a collection of pancreatic secretions encapsulated by granulation and fibrous tissue and occurs primarily in the setting of either acute and chronic pancreatitis. Clinical course may be asymptomatic, while abdominal pain, vomiting and other gastrointestinal symptoms are reported. The diagnosis is made by ultrasound and other imaging studies, while treatment can range from observation and conservative treatment to surgery.


Presentation

The clinical presentation of patients with pancreatic pseudocysts may vary significantly. The disease may have an asymptomatic course, in which little or no symptoms may be present. In most cases, nonspecific complaints of abdominal pain, nausea, bloating and vomiting are reported, which cannot immediately point to a pancreatic pseudocyst as the cause of symptoms. Pallor and weakness may be present in the case of bleeding and consequent anemia, while jaundice and fever may also be present [11]. In some cases, when larger cysts are present, an abdominal mass may be palpated during the physical examination, with a generally tender abdomen, especially in the cases with bleeding. In more severe cases, when rupture of pseudocysts occurs, hypotension and shock may be present, which necessitates rapid treatment.

Dyspnea
  • We report a rare case of a large mediastinal pancreatic pseudocyst compressing the left atrium and the esophagus and causing dyspnea, palpitations, and emesis.[ncbi.nlm.nih.gov]
  • Case presentation A 55-year-old man with a history of chronic pancreatitis was admitted with intermittent dyspnea, dysphagia and weight loss.[jmedicalcasereports.biomedcentral.com]
  • Most patients also complain of dyspnea secondary to accompanying pleural effusion [ 6–9 ]. Our patient also had bilateral pleural effusions. Most patients also experience weight loss secondary to dysphagia.[academic.oup.com]
Vomiting
  • The child was presented with fever, abdominal pain and vomiting for a period of 5 days. Ultrasonography and CT scan examinations were performed and biochemical and haematological investigations were undertaken.[ncbi.nlm.nih.gov]
  • The presenting complaints in our patient were epigastric mass and postprandial vomiting. He had recently undergone open cholecystectomy following recovery from gallstone pancreatitis. EID was performed under general anaesthesia.[ncbi.nlm.nih.gov]
  • A 19-year-old female presents with a one-week history of abdominal pain associated with nausea, vomiting, and headache.[ncbi.nlm.nih.gov]
  • See your doctor immediately if you have any of the following symptoms: high, persistent fever severe pain in your upper abdomen, with pain radiating to your back unexplained fainting vomiting blood weak, rapid heartbeat You should pay even closer attention[healthline.com]
Nausea
  • A 19-year-old female presents with a one-week history of abdominal pain associated with nausea, vomiting, and headache.[ncbi.nlm.nih.gov]
  • However, the patient presents 11 weeks after the surgical procedure, icteric, with a 72 hours episode of mesogastric pain, with nausea and emesis. Laboratory blood test showed an obstructive biliary pattern.[sages.org]
  • She presented abdominal pain, early satiety, and nausea during the previous 2 months. Presence of pancreatic pseudocysts of 92 and 62 mm was demonstrated by computed tomography. The patient was submitted to a laparoscopic cyst-gastric anastomosis.[ncbi.nlm.nih.gov]
Abdominal Mass
  • The patient presented with an abdominal mass involving the epigastrium, left hypochondrium, and left flank.[ncbi.nlm.nih.gov]
  • You may or may not also experience one or more of the following symptoms: Fever Nausea Vomiting Diarrhea Loss of appetite Weight loss Tender abdominal mass Jaundice (yellowing of the skin/eyes) A build-up of fluid within the abdominal cavity If you do[newhealthadvisor.com]
  • Case 2 A 70-year-old female with a previous history of pancreatitis presented to the emergency service as a palpapable abdominal mass.[saudijgastro.com]
  • The indication was an abdominal mass localized in the left upper quadrant that occured in the outcomes of an acute pancreatitis. He had a 40-year history of alcoholism and smocking.[pubs.sciepub.com]
  • Fever Swollen belly Nausea and vomiting An abdominal mass detected on physical exam Severe pancreatitis may also cause dehydration and low blood pressure. Complications from pseudocysts may cause other symptoms.[saintlukeskc.org]
Epigastric Pain
  • The palpation revealed epigastric pain and palpable pulsatile mass above the umbilicus. Laboratory tests showed increased serum and urine amylases.[ncbi.nlm.nih.gov]
  • A 56 years old man presented with epigastric pain and abdominal distension. He suffered an attack of acute pancreatitis 6 weeks back followed by pseudopancreatic cyst formation.[ncbi.nlm.nih.gov]
  • We reported a 54 year-old female treated for epigastric pain.[ncbi.nlm.nih.gov]
  • A 55-year-old man after acute pancreatitis presented with a 1-year history of epigastric pain and was admitted due to a postinflammatory pseudocyst in the body and tail of pancreas. On admission, blood tests, including CA 19-9 and CEA, were normal.[ncbi.nlm.nih.gov]
  • Meanwhile the patient was just complaining of epigastric pain that was well managed by analgesics. A conservative management was then decided. At the follow-up, CT scan was realized at the 1st, the 3rd and the 5th month.[pubs.sciepub.com]
Abdominal Distension
  • We report a case of a giant pancreatic pseudocyst in a 33-year-old woman presenting with abdominal pain, loss of appetite and abdominal distension.[ncbi.nlm.nih.gov]
  • We report a case of a giant pancreatic pseudocyst in a 65-year-old man presenting with abdominal pain, loss of appetite and abdominal distension.[ncbi.nlm.nih.gov]
  • A 56 years old man presented with epigastric pain and abdominal distension. He suffered an attack of acute pancreatitis 6 weeks back followed by pseudopancreatic cyst formation.[ncbi.nlm.nih.gov]
  • A 27-year-old Sri Lankan male, with history of heavy alcohol use, presented with progressive abdominal distension following an episode of acute pancreatitis.[ncbi.nlm.nih.gov]
  • Medical College, Gorakhpur with a two-day history of severe abdominal pain, abdominal distension, vomiting, palpitation and fever.[tropicalgastro.com]

Workup

The diagnostic workup of pancreatic pseudocysts includes a detailed approach to the patient. Initial patient history may provide important clues, such as a history of pancreatitis and progression of symptoms prior to admission. In all patients with nonspecific abdominal symptoms, ultrasonography can be very useful in differentiating pancreatic lesions from other processes in the abdomen. Cystic formations can be detected with ultrasonography which has very high specificity, low cost and easy availability making it an efficient method for initial diagnosis[12]. However, a definite diagnosis can be made by either CT or MRI, which can provide a better view into pancreatic tissue [13]. These imaging techniques can reveal the exact size and location of cysts, and can also establish whether more than one cyst is present. Endoscopic retrograde cholangiopancreatography (ERCP) is a useful, but invasive technique which is used for evaluation of surgical treatment. In some cases, a histological confirmation is necessary to differentiate pseudocysts from other cystic lesions that proliferate such as neoplasia. This can be achieved through endoscopic ultrasound and aspiration biopsy [6].

Mediastinal Mass
  • View Article PubMed Google Scholar Casson AG, Inculet R: Pancreatic pseudocyst: an uncommon mediastinal mass. Chest. 1990, 98: 717-718. 10.1378/chest.98.3.717.[jmedicalcasereports.biomedcentral.com]
  • Recent advances in endoscopic techniques, such as endoscopic ultrasound (EUS), are helpful not only in evaluating the mediastinal mass and cysts, but also play an important therapeutic role by allowing EUS-guided aspiration and drainage of the cyst [[academic.oup.com]
Pancreatic Calcification
  • Hemorrhagic, infected pseudocyst appears as lobulated, heterogeneous, mixed density lesion with or without pancreatic calcification. Main pancreatic duct (MPD) & common bile duct (CBD) dilatation can also be noted.[npplweb.com]
Mediastinal Shift
  • Chest X-ray and subsequent CT demonstrated a massive pleural effusion with mediastinal shift. Ultrasound scan demonstrated loculation of the effusion requiring insertion of a large bore chest drain to relieve symptoms.[ncbi.nlm.nih.gov]
Pseudomonas
  • The authors present a PET/CT scan showing abnormal uptake of 18F-Fluorodeoxyglucose-labeled autologous leukocytes in a pancreatic pseudocyst, from which aspirated fluid subsequently showed growth of Pseudomonas aeruginosa.[ncbi.nlm.nih.gov]
Lymphocytic Infiltrate
  • Histopathological examination revealed the existence of pseudocyst, significant lymphocytic infiltration, and fibrotic change in the pancreatic tail.[ncbi.nlm.nih.gov]

Treatment

There are several treatment modalities that can be used for managing pancreatic pseudocysts. For patients with a mild or asymptomatic clinical course, treatment may not be necessary, as pseudocysts tend to resolve spontaneously within several weeks. However, in patients with development of complications, progressively enlarging pseudocysts, and with poor general condition, one of several treatment procedures may be indicated:

  • Endoscopic drainage - The primary aim of surgical treatment is to provide a route for pseudocysts to drain into the gastrointestinal lumen and endoscopic drainage is the most commonly used method. There are several criteria which need to be fulfilled for this form of treatment to be indicated, such as wall thickness of the pseudocyst between 3-10mm, diameter of at least 5 cm and mechanical compression of the gastric wall [14]. There are two approaches, transmural and trans-papillary. Transmural drainage is indicated if imaging studies show a visible impression of the gastrointestinal system, in most cases the stomach or the duodenum, which enables placement of stents and drainage into the GI system [15]. On the other hand, trans-papillary drainage is indicated if the connection between the pseudocyst and the main pancreatic duct can be achieved by stenting [16]. Success rates are usually very high (>80%), but the recurrent development of pseudocysts as well as complications from both methods can occur, which is why careful evaluation must be done before choosing optimal therapy [17].
  • Percutaneous drainage - This method is sometimes used as an alternative form of treatment. Possible routes include transperitoneal, transgastric, transduodenal, as well as several other approaches, but because of several complications that are not uncommon, including cellulitis at the site of puncture, catheter occlusion, and sepsis, these techniques is now less frequently used.
  • Surgical drainage - Patients with a more complicated condition are usually treated by either laparoscopy or open surgery [18], with subsequent cyst excision and drainage. Internal drainage of cysts can be performed through pseudocystoduodenostomy and pseudocystogastrostomy, which show very good success rates with rare complications [19]. Resection of cysts, through partial pancreatectomy, is an alternative method as well. Laparoscopic approach to patients with pancreatic pseudocysts is becoming a favorable option with very high success rates [20].

Prognosis

The prognosis of patients with pancreatic pseudocysts depends on various factors, as the cause and course of the disease have a significant impact on the outcome. The presence of asymptomatic or mild form of the disease is known to result in spontaneous resolution of pseudocysts. [8]. but several complications may arise. They include abscess formation and sepsis, while rupture with or without hemorrhage is a particularly troubling issue, since it may be life-threatening. Mortality rates are about 60% and 15% in rupture of pseudocysts with and without hemorrhage, respectively, which is why this condition should be considered in all patients with complications of pancreatitis [4]. Other complications include obstruction of the gastric outlet and biliary obstruction, as well as thrombosis of the portal venous system [9]. Bleeding can also occur as a result of pseudoaneurysm formation, which is seen in about 10% of patients, most commonly involving the splenic artery and can necessitate rapid surgical treatment to prevent severe blood loss. Alcohol abuse as a cause of pseudocyst formation is known to significantly increase the risk for complications. in addition, the size and location of the cyst also contribute significantly to the complication rate as cysts that developed in the tail, or those smaller than 5 cm in diameter almost always regressed spontaneously [10].

Etiology

Pseudocysts of the pancreas are formed due to leakage of pancreatic juices and their encapsulation into fibrous tissue as a result of increased pressures and damage of the pancreatic duct. The most common cause for this event is pancreatitis, either acute or chronic [2], while trauma, infection and neoplasia may be a potential cause as well. Sometimes, the cause of pseudocyst formation may remain unknown (idiopathic pancreatitis), which is seen in approximately 15-25% of cases [4].

Epidemiology

It is estimated that around 15% of patients with acute pancreatitis develop pseudocysts, while significantly higher rates of about 40% are observed in chronic pancreatitis. [5]. However, highest incidence rates were observed in chronic pancreatitis related to alcohol abuse [6], implying that alcohol abuse is one of the most important risk factors. Gallstone formation is also an important risk factor, because of its involvement in the pathogenesis of acute pancreatitis. Pseudocysts are usually seen in male adults, due to the fact that pancreatitis and alcohol abuse are more frequently encountered amongst males. Pancreatic pseudocyst formation can be seen in children as well, but the cause is primarily abdominal trauma.

Sex distribution
Age distribution

Pathophysiology

The pathogenesis of pancreatic pseudocysts significantly differs in patients with acute and chronic pancreatitis [2]. Regardless of the cause, the end-result is leakage of pancreatic juices consisting of amylase, lipase, and trypsin from the pancreatic duct and their entrapment in layers of fibrous tissue. The reason why the term "pseudocyst" is used is because there is an absence of the epithelial layer of cells, as the wall of the cyst is composed of fibroblasts and granulation tissue entirely. In the setting of acute pancreatitis, gallstones are the primary cause of impaired flow of bile and pancreatic content. Because of minimal damage to the pancreatic duct, smaller quantities of pancreatic juices exit the ducts and eventually form cysts that are less likely to cause complications. In the case of chronic pancreatitis with alcohol abuse, there is progressive damage to the parenchyma, including the pancreatic duct. Disruption of architecture by alcohol, activation of pancreatic stellate cells and subsequent collagen deposition lead to significant damage to the pancreatic duct, which may be massively dilated, or in severe cases obliterated, leading to accumulation of larger cysts [2]. Sometimes, more than one cyst may be present, which is especially the case in chronic forms of pancreatitis [7].

Prevention

Since the formation of pseudocysts is closely related to both acute and chronic pancreatitis and the risk factors for these conditions are preventable, the development of pseudocysts can be prevented. Alcohol consumption is established to be the single most important factor for the development of chronic pancreatitis, implying that reduction in alcohol consumption may significantly reduce the risk. On the other hand, acute pancreatitis is known to be associated with development of gallstones, which can be reduced through proper dietary habits and pharmacologic management when indicated.

Summary

Pancreatic pseudocyst is a formation composed of pancreatic secretions and juices enclosed by fibrous tissue. The term "pseudo" implies the cyst is lacking the epithelial cell layer and is formed under circumstances of extensive pressures in the pancreatic ducts, which most frequently develops in the setting of acute and chronic pancreatitis [1]. It is established that approximately 15% of patients who suffer from acute pancreatitis develop pseudocysts, while much higher prevalence rates of almost 40% are observed in patients with chronic pancreatitis [2]. Another potential cause, although much less common than the former two, can be trauma. The pathogenesis of pseudocyst formation in acute pancreatitis is significantly different as compared to in patients with chronic pancreatitis, but invariably involves structural changes and damage of the main pancreatic duct, leading to leakage of pancreatic juices. In acute pancreatitis, gallstones are the most common cause of ductal damage, usually in only a few sites, while chronic pancreatitis is characterized by chronic alcohol ingestion and severe disruption of the pancreatic parenchyma, lead to significant damage of the ductal system. In addition, extensive deposition of collagen and fibrosis occurs in the setting of chronic pancreatitis, which further contributes to development of pseudocysts. Pseudocysts usually develop over the course of several weeks after the onset of pancreatitis [3], and more than one cyst may develop, which is more commonly seen in patients with chronic pancreatitis. Pseudocysts may be asymptomatic and resolve without treatment, or they may cause significant morbidity and cause major complications. Abscess formation, rupture and hemorrhage can occur and it is established that mortality rates from rupture of pseudocysts without hemorrhage are around 14%, while accompanying hemorrhage raises mortality rates up to 60% [4]. For these reasons, establishing a diagnosis early on may significantly reduce potentially fatal sequelae of this condition. The clinical presentation of patients may be asymptomatic, but when symptoms are present, they may be nonspecific and include abdominal pain, nausea, vomiting, bloating, fever and jaundice. Larger cysts may compress adjacent organs and cause symptoms such as cholangitis in the setting of biliary obstruction, while severe blood vessel obstruction, most commonly the splenic and superior mesenteric artery, can cause significant anemia and blood loss. In some cases, secondary infection may occur and lead to sepsis without appropriate treatment. Special attention should be given to lesions that are growing in size, because they are more prone to cause complications. Pancreatic pseudocysts can be initially detected by ultrasonography, while a definite diagnosis can be made by either computed tomography (CT) or magnetic resonance imaging (MRI). Because pancreatic pseudocysts comprise about 15% of all cystic formations in the pancreas, they should be differentiated from other cystic formations that may be malignant, which can sometimes require histological examination. Serial radiographic imaging should be performed to assess the progression of the lesion. Blood workup should be performed in all patients, including a complete blood count (CBC), levels of pancreatic enzymes, inflammatory markers, as well as evaluation of other organs, including the liver and the kidneys. In mild cases, spontaneous resolution frequently occurs and only conservative therapy may be sufficient, while more severe cases require a surgical approach. Regardless of the choice of surgery, the aim is either to provide a connection between the gastrointestinal system and the cyst so that internal drainage can be achieved, or to remove the cyst by excision. The choice of surgical treatment depends on the cyst size, location and on the presence of accompanying complications.

Patient Information

Pancreatic pseudocyst is a term that describes a formation of a cyst filled with pancreatic juice inside the pancreas, with the term "pseudo" (meaning "false") indicating that not all features are shared with classical cysts. In the vast majority of patients, pancreatic pseudocysts develop on the basis of either acute, but more commonly chronic pancreatitis, while trauma may also be a potential cause. Gallstones are the main risk factor and cause of acute pancreatitis, while alcohol abuse is the single most important risk factor for chronic pancreatitis. In either case, damage to the main duct of the pancreas causes leakage of pancreatic secretions and their subsequent entrapment into a layer of fibrous tissue. It is established that up to 15% of patients with acute and 40% of patients with chronic pancreatitis develop pseudocysts. Development of pseudocysts can have an asymptomatic course, meaning that symptoms are absent and the diagnosis can be made incidentally. But complications do occur in a substantial number of patients and some of them may be life-threatening, which is why a prompt diagnosis can be life-saving. Symptoms, when present, may include fever, abdominal pain, nausea, vomiting, appetite problems, and jaundice. Patients with a more severe course of the disease may experience anemia, hypotension, and shock. Complications include rupture of pseudocysts which can be accompanied with bleeding, while a secondary infection with development of sepsis may occur as well. For these reasons, ultrasonography is the initial diagnostic method of choice, as it is cheap and readily available, but more importantly, a very useful method to determine the cause of the symptoms. To confirm the exact location, size, but also number of cysts, either computed tomography (CT scan) or magnetic resonance imaging (MRI) should be performed. In some cases, when imaging techniques cannot differentiate pseudocysts with other similar lesions that can turn out to be cancerous, a sample of the cyst can be obtained for microscopic evaluation. Patients with mild complaints may not require therapy, as pseudocysts in the pancreas tend to resolve spontaneously within several weeks, but for patients with a severe disease course, treatment almost always includes some form of surgery. The goal of therapy is to eliminate the pseudocysts by either creating a pathway for them to drain into the gastrointestinal tract (because they are often in close proximity to the stomach or the duodenum) or in some cases, excision by either laparoscopic or open surgery can be performed. Pancreatic pseudocysts can pose a life-threatening risk to the patient, which is why a prompt diagnosis is essential in ensuring little or no complications of the disease.

References

Article

  1. Bradley EL III. A clinically based classification system for acute pancreatitis. Summary of the International Symposium on Acute Pancreatitis, Atlanta, GA, September 11 through 13, 1992. Arch Surg 1993;128:586–590.
  2. Behrns KE1, Ben-David K. Surgical therapy of pancreatic pseudocysts. J Gastrointest Surg. 2008;12(12):2231-2239.
  3. Brun A, Agarwal N, Pitchumoni CS. Fluid collections in and around the pancreas in acute pancreatitis. J Clin Gastroenterol. 2011;45(7):614-625.
  4. Porter RS, Kaplan JL. Merck Manual of Diagnosis and Therapy. 19th Edition. Merck Sharp & Dohme Corp. Whitehouse Station, N.J; 2011.
  5. Aghdassi AA, Mayerle J, Kraft M, Sielenkämper AW, Heidecke C-D, Lerch MM. Pancreatic pseudocysts – when and how to treat? HPB : The Official Journal of the International Hepato Pancreato Biliary Association. 2006;8(6):432-441.
  6. Lankisch PG, Weber-Dany B, Maisonneuve P, Lowenfels AB. Pancreatic pseudocysts: prognostic factors for their development and their spontaneous resolution in the setting of acute pancreatitis. Pancreatology. 2012;12(2):85-90.
  7. Rosso E, Alexakis N, Ghaneh P, Lombard M, Smart HL, Evans J, et al. Pancreatic pseudocyst in chronic pancreatitis: endoscopic and surgical treatment. Dig Surg. 2003;20:397–406.
  8. Cooperman AM. An Overview of Pancreatic Pseudocysts. The Emperor's New Clothes Revisited Surgical Clinics of North America 2001- Volume 81, Issue 2.
  9. Heider TR, Azeem S, Galanko JA, Behrns KE. The natural history of pancreatitis-induced splenic vein thrombosis. Ann Surg 2004;239:876–880.
  10. Maringhini A, Uomo G, Patti R, Rabitti P, Termini A, Cavallera A, et al. Pseudocysts in acute nonalcoholic pancreatitis: incidence and natural history. Dig Dis Sci. 1999;44:1669–1673.
  11. Gouyon P, Levy P, Ruszniewski P, Zins M, et al. Predictive factors in the outcome of pseudocysts complicating alcoholic chronic pancreatitis. Gut. 1997;41: 821-825.
  12. O'Malley VP, Cannon JP, Postier RG. Pancreatic pseudocysts: cause, therapy, and results. Am J Surg 1985;150:680-682.
  13. Zheng M, Qin M. Endoscopic ultrasound guided transgastric stenting for the treatment of traumatic pancreatic pseudocyst. Hepatogastroenterology. 2011;58(109):1106-1109.
  14. Thoeni RF. The revised Atlanta classification of acute pancreatitis: its importance for the radiologist and its effect on treatment. Radiology. 2012;262(3):751-764.
  15. Sakorafas GH, Sarr MG. Cystic neoplasms of the pancreas; what a clinician should know. Cancer Treat Rev. 2005;31:507–535.
  16. Binmoeller KF, Seifert H, Walter A, Soehendra N. Transpapillary and transmural drainage of pancreatic pseudocysts. Gastrointest Endosc. 1995;42:219–224.
  17. Jani N, Bani Hani M, Schulick RD, Hruban RH, Cunningham SC. Diagnosis and Management of Cystic Lesions of the Pancreas. Diagnostic and Therapeutic Endoscopy. 2011;2011:478913.
  18. Aljarabah M, Ammori BJ. Laparoscopic and endoscopic approaches for drainage of pancreatic pseudocysts: a systematic review of published series. Surg Endosc. 2007;21(11):1936-1944.
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Last updated: 2018-06-22 01:51