Pancreatic Pseudocysts

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Practice Essentials

Pancreatic pseudocysts (see the image below) are best defined as localized fluid collections that are rich in amylase and other pancreatic enzymes, that have a nonepithelialized wall consisting of fibrous and granulation tissue, and that usually appear several weeks after the onset of pancreatitis. They are to be distinguished from acute fluid collections, organized necrosis, and abscesses.



View Image

Three views of a pancreatic pseudocyst noted during endoscopic ultrasound. The concentric rings in the center of the images are produced by the ultras....

Signs and symptoms

No specific set of symptoms is pathognomonic of pseudocysts; however, the following are suggestive:

Physical examination findings are of limited sensitivity but may include the following:

See Presentation for more detail.

Diagnosis

Laboratory studies that may be considered include the following:

Imaging studies that may be helpful include the following:

See Workup for more detail.

Management

Most pseudocysts resolve without interference and only require supportive care. For some, drainage is indicated. Indications for drainage include the following:

Drainage options are as follows:

No medications are specific to the treatment of pancreatic pseudocysts. Antibiotics and octreotide may be useful adjuncts in some cases.

See Treatment and Medication for more detail.

Background

Pseudocysts are best defined as localized fluid collections that are rich in amylase and other pancreatic enzymes, that have a nonepithelialized wall consisting of fibrous and granulation tissue, and usually appears several weeks after the onset of pancreatitis.[1]

These characteristics contrast with those of acute fluid collections, which are more evanescent and are serosanguinous inflammatory reactions to acute pancreatitis. These collections are noted in moderate-to-severe pancreatitis. Acute fluid collections usually have an irregular shape and lack a well-defined wall. In general, they resolve in about 65% of cases.

Two other types of fluid collection should be considered. First, an organized necrosis is actually devitalized pancreatic tissue that appears cystlike on computed tomography (CT) scans, but it appears to be solid on other imaging modalities. Second, an abscess is an infected area of necrosis or fluid.

Acute or, rarely, chronic pancreatitis or abdominal trauma causes pseudocysts. If no history of pancreatitis or trauma exists, the diagnosis must be carefully confirmed.

Single or multiple fluid collections that look like cysts on pancreatic imaging are often observed during acute pancreatitis. Because of increasing sensitivity of imaging modalities and improvements in technology providing enhanced therapeutic abilities, the question arises as to when and whether drainage should be performed and what modality should be used to drain the cysts.[2] Strictly defining the type of fluid collection is very important when reviewing pancreatic fluid collections. The therapeutic approach is different depending on the type of collection.

Pathophysiology

Pancreatic pseudocysts can be single or multiple. Multiple cysts are more frequently observed in patients with alcoholism, and they can be multiple in about 15% of cases. Size varies from 2-30 cm. About one third of pseudocysts manifest in the head of the gland, and two thirds appear in the tail. The fluid in pseudocysts has been well characterized as clear or watery, or it can be xanthochromic. The fluid in pseudocysts usually contains very high amounts of amylase, lipase, and trypsin, though the amylase level may decrease over time.

The pathogenesis of pseudocysts seems to stem from disruptions of the pancreatic duct due to pancreatitis and extravasation of the enzymatic material. Two thirds of patients with pseudocysts have demonstrable connections to the pancreatic duct. In the other third, an inflammatory reaction is supposed to have sealed the connection so that it is not demonstrable. The cause of pseudocysts parallels the cause of acute pancreatitis; 75-85% of cases are caused by alcohol or gallstone disease–related pancreatitis. In children, pseudocysts and trauma are frequently associated.

Epidemiology

Sex- and age-related demographics

The male predominance in the incidence of pseudocysts mirrors the male predominance in the incidence of pancreatitis.

Pseudocysts may occur after pancreatitis in any age group. In children, pseudocysts are most likely observed after abdominal trauma. In elderly persons, care should be taken not to confuse cystic neoplasms with pseudocysts.

Prognosis

Most pseudocysts resolve without interference, and patients do well without intervention. The outcome is much worse for patients who develop complications or who have the cyst drained. The presence of pancreatic necrosis is a poor prognostic sign.

The failure rate for drainage procedures is about 10%, the recurrence rate is about 15%, and the complication rate is 15-20%.

Complications

Bleeding is the most feared complication and is caused by the erosion of the pseudocyst into a vessel. Consider the possibility of bleeding in any patient who has a sudden increase in abdominal pain coupled with a drop in hematocrit level or a change in vital signs. Therapy is emergent surgery or angiography with embolization of the bleeding vessel.

Do not perform a percutaneous or endoscopic drainage procedure under any circumstances in patients with suspected bleeding into a pseudocyst. Consider the possibility of infection of the pseudocyst in patients who develop fever or an elevated WBC count. Treat infection with antibiotics and urgent drainage.

GI obstruction, manifesting as nausea and vomiting, is an indication for drainage.

The pseudocyst can also rupture. A controlled rupture into an enteric organ occasionally causes GI bleeding. On rare occasions, a profound rupture into the peritoneal cavity causes peritonitis and death.

Patient Education

Patients who are being managed expectantly must be educated about the warning signs for potential complications (eg, abdominal pain, fever), which may indicate bleeding, infection, or pseudocyst rupture.

For patient education resources, see the Digestive Disorders Center, as well as Pancreatitis and Abdominal Pain in Adults.

History

No specific set of symptoms is pathognomic of pseudocysts; however, consider the possibility of a pseudocyst in a patient who has persistent abdominal pain, anorexia, or an abdominal mass after an episode of pancreatitis.

Rarely, patients present with jaundice or sepsis from an infected pseudocyst.

Pleural effusion is also a common finding.

Physical Examination

The sensitivity of physical examination findings is limited. Patients very frequently have a tender abdomen. Patients occasionally have a palpable mass in the abdomen.

Peritoneal signs suggest rupture of the cyst or infection.

Other possible findings include the following:

Complications

Bleeding is the most feared complication and is caused by the erosion of the pseudocyst into a vessel. Consider the possibility of bleeding in any patient who has a sudden increase in abdominal pain coupled with a drop in hematocrit level or a change in vital signs. Therapy is emergent surgery or angiography with embolization of the bleeding vessel.

Do not perform a percutaneous or endoscopic drainage procedure under any circumstances in patients with suspected bleeding into a pseudocyst.

Consider the possibility of infection of the pseudocyst in patients who develop fever or an elevated WBC count. Treat infection with antibiotics and urgent drainage.

GI obstruction, manifesting as nausea and vomiting, is an indication for drainage.

The pseudocyst can also rupture. A controlled rupture into an enteric organ occasionally causes GI bleeding. On rare occasions, a profound rupture into the peritoneal cavity causes peritonitis and death.

Laboratory Studies

Serum tests have limited use. Amylase and lipase levels are often elevated but may be within the reference ranges. Bilirubin and liver function test (LFT) findings may be elevated if the biliary tree is involved.

Analysis of the cyst fluid may help differentiate pseudocysts from tumors. An attempt should be made to exclude tumors in any patient who does not have a clear history of pancreatitis. Note the following:

Ultrasonography

Abdominal ultrasonography

Abdominal ultrasonography may be used to visualize cystic fluid collections in and around the pancreas. However, the technique is limited by the operator’s skill, the patient's habitus, and any overlying bowel gas. As such, ultrasonography is not the study of choice to establish a diagnosis.

Endoscopic ultrasonography

Endoscopic ultrasonography (EUS) is not necessary to establish a diagnosis but is very important in planning therapy, particularly if endoscopic drainage is contemplated.

A gastric wall thickness greater than 1 cm next to the cyst tends to predict a poor outcome with endoscopic drainage.

EUS may also be helpful in detecting small portal collaterals from otherwise undetected portal hypertension that may increase bleeding risks with transmural drainage.

Transmural drainage may be performed only when a symptomatic pseudocyst is positioned next to the gut wall. See the image below.



View Image

Three views of a pancreatic pseudocyst noted during endoscopic ultrasound. The concentric rings in the center of the images are produced by the ultras....

Computed Tomography Scanning

Abdominal computed tomography (CT) scanning is the imaging criterion standard for pancreatic pseudocysts. It has a sensitivity of 90-100% and is not operator dependent. Note the following:

Endoscopic Retrograde Cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP) is not necessary in diagnosing pseudocysts; however, it is useful in planning drainage strategy.

A study by Neil et al investigated the use of ERCP and the treatment of pseudocysts and acute pancreatitis and reported that a change in management occurred 35% of the time after the ERCP findings in pseudocysts were evaluated. Therefore, many authors recommend performing an ERCP before contemplated drainage procedures.

Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) is not necessary to establish a diagnosis of pseudocysts; however, it is useful in detecting a solid component in the cyst and in differentiating between organized necrosis and a pseudocyst.

A solid component makes catheter drainage difficult; therefore, in the setting of acute necrotizing pancreatitis with resultant pseudocyst, an MRI may be very important before a planned catheter drainage procedure.

Histologic Findings

Histologic findings vary with age because older cysts have thicker walls with more collagen. The etiology of the cyst does not change the histology. Note the following zone features:

Medical Care

The goal of therapy is avoidance of complications. Note the following:

Indications for drainage include the following:

Consultations

Management of pseudocysts requires a team approach. Gastroenterologists, surgeons, and invasive radiologists must work together to determine the necessity, timing, and method of intervention. If nonsurgical drainage is contemplated, it is important to elucidate the anatomy of the pancreatic duct beforehand. This may be done via endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance imaging (MRI). A large number of patients who fail or have complications with nonsurgical drainage have disruption or stenosis of the pancreatic duct.

Diet and activity

Patients may eat a low-fat diet as tolerated. Patients in whom eating causes abdominal pain need parenteral or enteral nutrition through a percutaneously or endoscopically placed jejunal tube.

Patients may engage in activities as tolerated.

Outpatient monitoring

Patients who have endoscopically placed stents must be monitored via serial computed tomography (CT) scans to observe resolution of the cyst. Stents may then be endoscopically removed after resolution.

Closely monitor patients with percutaneous drains for pain, infection, or catheter migration. Remove the drain when drainage ceases.

Surgical Care

Drainage options are outlined below.

Catheter drainage

Percutaneous aspiration is useful only to establish a diagnosis or as a temporizing measure. It has a 54% failure rate and a 63% recurrence rate. This technique has a relatively high risk of infecting the pseudocyst. Percutaneous drainage may have a higher complication rate and inpatient mortality rate than surgical drainage.

Percutaneous catheter drainage is the procedure of choice for treating infected pseudocysts, allowing for rapid drainage of the cyst and identification of any microbial organism. A high recurrence and failure rate exist, but catheter drainage may be a good temporizing measure.

Percutaneous catheter drainage is contraindicated in patients who are poorly compliant and cannot manage a catheter at home. It is also contraindicated in patients with strictures of the main pancreatic duct and in patients with cysts containing bloody or solid material.

Endoscopic drainage

Endoscopic drainage may be either transpapillary (via endoscopic retrograde cholangiopancreatography [ERCP]) or transmural. Both modalities require careful patient selection to ensure success and safety.

Transpapillary drainage

Transpapillary drainage, while safer and more effective than transmural drainage, requires cyst communication with the pancreatic duct. This technique may be technically challenging because it requires wire passage and stenting through the pancreatic duct to the pseudocyst. The success rate is about 80%. The recurrence rate is 10-14%, and, in most series, the complication rate (mainly pancreatitis) is approximately 13%.[4] See the image below.



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These photographs show the endoscopic view of transpapillary pseudocyst drainage in a patient with pancreas divisum and a pseudocyst that communicates....

Transmural drainage

Endoscopic transmural drainage is also possible.[5] This involves performing an endoscopy and finding a bulge into the lumen of the stomach or duodenum caused by compression of the pseudocyst. The cyst is generally entered using a needle knife to cut through the gastric or duodenum wall, and a series of pigtail stents are placed through the resulting communication. Some have adapted the technique to avoid diathermy, thus decreasing possible complications. The method has an 82-89% success rate in very experienced hands. The recurrent rate is 6-18%. The complication rate is 20%, with the most feared complication being bleeding.

One report suggested that the complication rate decreases and the efficacy increases with experience. Weckman reported an approximately 86% success rate with endoscopic drainage with a 10% complication rate and a 14% failure rate.[6] There appeared to be about a 15% recurrence rate. There was no real difference in outcome in patients treated with a transpapillary or transmural approach.

In December 2013, the FDA approved marketing of the AXIOS Stent and Delivery System for the treatment of pancreatic pseudocysts.[7] Approval of the stent, which creates a new temporary opening between the pancreas and the gastrointestinal tract, was based on a study of 33 patients with pancreatic pseudocysts at least 6 cm in diameter.[7] In this study, stents were successfully placed 90.9% of the time, 97% of the successfully implanted stents stayed in place for the duration of treatment, 93% of the stents remained open to allow drainage for the duration of treatment, and 86% of the treated pseudocysts decreased in size by at least 50%.[7]

Surgical drainage

Surgical drainage is the criterion standard against which all therapies are measured.

Internal drainage is the procedure of choice. A laparoscopic approach has been used in some cases with good results.[8]

In most series, the mortality rate is 3%, and the complication rate is approximately 24%. The success rate is 85-90%.

Relatively recent studies have suggested that a laparoscopic approach to drainage has a high success rate and a low morbidity rate.[9, 10]

Medication Summary

No medications are specific to the treatment of pancreatic pseudocysts. Antibiotics are an adjunct to drainage of infected pseudocysts. Octreotide can be useful as an adjunct to catheter drainage.

Octreotide (Sandostatin)

Clinical Context:  Acts primarily on somatostatin receptor subtypes II and V. Inhibits growth hormone (GH) secretion and has a multitude of other endocrine and nonendocrine effects, including inhibition of glucagon, VIP, and GI peptides.

Class Summary

Used to reduce pancreatic exocrine secretion.

How are pancreatic pseudocysts defined?What are the signs and symptoms of pancreatic pseudocysts?Which physical findings suggest pancreatic pseudocysts?Which lab tests are performed in the workup of pancreatic pseudocysts?Which imaging studies are performed in the workup of pancreatic pseudocysts?When is drainage indicated in the treatment of pancreatic pseudocysts?What are the drainage options for pancreatic pseudocysts?What is the role of drug treatment for pancreatic pseudocysts?What are pancreatic pseudocysts?What is the pathophysiology of pancreatic pseudocysts?Which patient groups have the highest prevalence of pancreatic pseudocysts?What is the prognosis of pancreatic pseudocysts?What are the possible complications of pancreatic pseudocysts?What is included in patient education about pancreatic pseudocysts?Which clinical history findings are characteristic of pancreatic pseudocysts?What is the clinical presentation of pancreatic pseudocysts?How is bleeding managed in pancreatic pseudocysts?How is infection treated in pancreatic pseudocysts?What are the possible GI complications of pancreatic pseudocysts?Which conditions should be included in the differential diagnoses of pancreatic pseudocysts?What are the AGA recommendations for the diagnosis and treatment of asymptomatic neoplastic pancreatic cysts?What are the differential diagnoses for Pancreatic Pseudocysts?What is the role of lab tests in the workup of pancreatic pseudocysts?What is the role of EUS in the workup of pancreatic pseudocysts?What is the role of abdominal ultrasonography in the workup of pancreatic pseudocysts?What is the role of CT scanning in the workup of pancreatic pseudocysts?What is the role of ERCP in the workup of pancreatic pseudocysts?What is the role of MRI in the workup of pancreatic pseudocysts?Which histologic findings are characteristic of pancreatic pseudocysts?How are pancreatic pseudocysts treated?Which specialist consultations are beneficial to patients with pancreatic pseudocysts?Which dietary and activity modifications are used in the treatment of pancreatic pseudocysts?What is included in long-term monitoring of patients with pancreatic pseudocysts?What is the role of endoscopic transpapillary drainage in the treatment of pancreatic pseudocysts?What is the role of catheter drainage in the treatment of pancreatic pseudocysts?What is the role of endoscopic drainage in the treatment of pancreatic pseudocysts?What is the role of endoscopic transmural drainage in the treatment of pancreatic pseudocysts?What is the role of surgical drainage in the treatment of pancreatic pseudocysts?Which medications are used in the treatment of pancreatic pseudocysts?Which medications in the drug class Somatostatin analogues are used in the treatment of Pancreatic Pseudocysts?

Author

Louis R Lambiase, MD, MHA, Professor of Medicine, University of Tennessee College of Medicine Chattanooga; Chief, Division of Gastroenterology, University of Tennessee Chattanooga Unit; Assistant Dean for Clinical Affairs, University of Tennessee College of Medicine Chattanooga

Disclosure: Nothing to disclose.

Specialty Editors

Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

BS Anand, MD, Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

Disclosure: Nothing to disclose.

Additional Contributors

David Greenwald, MD, Professor of Clinical Medicine, Fellowship Program Director, Department of Medicine, Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine

Disclosure: Nothing to disclose.

Acknowledgements

Simmy Bank, MD Chair, Professor, Department of Internal Medicine, Division of Gastroenterology, Long Island Jewish Hospital, Albert Einstein College of Medicine

Disclosure: Nothing to disclose.

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Three views of a pancreatic pseudocyst noted during endoscopic ultrasound. The concentric rings in the center of the images are produced by the ultrasound transducer in the stomach. The cyst is observed as the large hypoechoic structure adjacent to the transducer.

Three views of a pancreatic pseudocyst noted during endoscopic ultrasound. The concentric rings in the center of the images are produced by the ultrasound transducer in the stomach. The cyst is observed as the large hypoechoic structure adjacent to the transducer.

These photographs show the endoscopic view of transpapillary pseudocyst drainage in a patient with pancreas divisum and a pseudocyst that communicates with the pancreatic duct. The image on the left shows the ampullary area. The middle image shows a wire placed in the minor papilla into the dorsal pancreatic duct. The right image shows a stent in place in the minor papilla.

Three views of a pancreatic pseudocyst noted during endoscopic ultrasound. The concentric rings in the center of the images are produced by the ultrasound transducer in the stomach. The cyst is observed as the large hypoechoic structure adjacent to the transducer.

These photographs show the endoscopic view of transpapillary pseudocyst drainage in a patient with pancreas divisum and a pseudocyst that communicates with the pancreatic duct. The image on the left shows the ampullary area. The middle image shows a wire placed in the minor papilla into the dorsal pancreatic duct. The right image shows a stent in place in the minor papilla.