1. Dr Batool Urooj Rajput
Dr Muhammad Sameer

2. 23 year old male, with no known co-morbids
admitted through OPD, with complains of:
 Abdominal fullness  1 year
 Nausea and vomiting  1 year

3.  Trauma followed by abdominal pain on
6/9/12.
 3 mo later, abdominal pain & vomiting ass
with food,
 CT scan on 27/11/12  large cystic mass in
upper left abdomen.
 Endoscopic drainage  22/1/13

4.  Two months later , abdominal fullness &
distention ass nausea & vomiting.
 U/S(28/7/13)  Pseudo pancreatic cyst &
Left Hydronephrosis.

5.  Not Significant
Personal History
 3 kg weight loss
 Allergy  nil
 Drug  antiemetic

6.  Father & sister  TB
 Mother  HTN
Socio-Economic History
 N/S

7.  Young male of lean built and average height ,
well oriented to time , place and person.
 B/P : 120/80
 Pulse : 90
 Temp : A/f
 R/R : 18
SubVitals : A*, Cl*, J* Cy*, D*, E*, L/N*

8.  CVS: S1 + S2 + 0
 CNS: Intact
 Chest: NVB + clear
 Abdomen:
◦ On inspection : distended, umbilicus obliterated, no
scar mark , no pigmentation
◦ On palpation : Firm, nontender , large 15 * 15 cm
swelling in LHC extending till epigastrium &
periumbilical area, fixed with regular border &
smooth surface.
◦ Rest of examination was normal.

9.  Pseudo pancreatic cyst
 Acute pancreatic fluid collection
 Pancreatic Abscess
 Mucinous cyst adenoma

10.  CBC
 UCE
 LFT
 PT INR
 Amylase

11.  A large cyst measuring 18.8*11cm seen in
the body and tail of pancreas suggestive of
pseudo cyst.

13.  Pseudo pancreatic Cyst

14.  Most common cystic lesions of the
pancreas, accounting for 75-80% of such
masses
 Location
◦ Lesser peritoneal sac in proximity to the pancreas
◦ Large pseudocysts can extend into the paracolic
gutters, pelvis, mediastinum, neck or scrotum
 May be loculated

15.  Thick fibrous capsule – not a true epithelial
lining
 Pseudo cyst fluid
◦ Similar electrolyte concentrations to plasma
◦ High concentration of amylase, lipase, and
enterokinases such as trypsin

16.  Pancreatic ductal disruption 2 to
1. Acute pancreatitis – Necrosis
2. Chronic pancreatitis – Elevated pancreatic duct
pressures from strictures or ductal calculi
3. Trauma
4. Ductal obstruction and pancreatic neoplasms

17.  Symptoms
◦ Abdominal pain > 3 weeks (80 – 90%)
◦ Nausea / vomiting
◦ Early satiety
◦ Bloating, indigestion
 Signs
◦ Tenderness
◦ Abdominal fullness

18.  Clinically suspect a pseudo cyst
◦ Episode of pancreatitis fails to resolve
◦ Amylase levels persistently high
◦ Persistent abdominal pain
◦ Epigastric mass palpated after pancreatitis
 Labs
◦ Persistently elevated serum amylase
 Plain X-ray
◦ Not very useful
 Ultrasound
◦ 75 -90% sensitive
 CT
◦ Most accurate (sensitivity 90-100%)

22. TEST Pancreatic
Fluid
Collection
Mucinous
cyst
adenoma
Pancreatic
Abscess
Pseudo cyst
CEA Low High Low Low
Amylase High Low High High
Mucin Stain Negative Positive Negative Negative

23.  ~50% resolve spontaneously
 Size
◦ Nearly all <4cm resolve spontaneously
◦ >6cm 60-80% persist, necessitate intervention
 Cause
◦ Traumatic, chronic pancreatitis <10% resolve
 Multiple cysts – few spontaneously resolve
 Duration - Less likely to resolve if persist >
6-8 weeks

24.  Infection
◦ S/S – Fever, worsening abd. pain, systemic signs of
sepsis
◦ CT – Thickening of fibrous wall or air within the
cavity
 GI obstruction
 Perforation
 Hemorrhage
 Thrombosis – SV (most common)
 Pseudo aneurysm formation – Splenic artery
(most common), GastroDuodenalArtery,
Post. Descending Artery

25.  Regardless of size, an asymptomatic pseudo
cyst does not require treatment.
 Abdominal ultrasonography every 3
to 6 months.
 ERCP is usually done before
attempting drainage

26. 
◦ Presence of symptoms (> 6 wks)
◦ Enlargement of pseudo cyst ( > 6 cm)
◦ Complications (infected cyst, progressive cyst,
multiple cysts, cyst due to trauma and
communicating cyst)
◦ Suspicion of malignancy

27. ◦ Percutaneous drainage
◦ Endoscopic drainage
◦ Surgical drainage

28.  Continuous drainage until output < 50
ml/day + amylase activity ↓
 Failure rate 16%
 Recurrence rates 7%
 Complications
 Conversion into an infected pseudo cyst (10%)
 Catheter-site cellulitis
 Damage to adjacent organs
 Pancreatico-cutaneous fistula
 GI hemorrhage

29.  Indications
◦ Mature cyst wall < 1 cm thick
◦ Adherent to the duodenum or posterior gastric wall
◦ Previous abd surgery or significant co morbidities
 Contraindications
◦ Bleeding dyscrasias
◦ Gastric varices
◦ Acute inflammatory changes that may prevent cyst
from adhering to the enteric wall
◦ CT findings
 Thick debris
 Multiloculated pseudocysts

30.  Excision
◦ Tail of gland & along with proximal strictures – distal
pancreatectomy & splenectomy
◦ Head of gland with strictures of pancreatic or bile ducts
– pancreaticoduodenectomy
 External drainage
 Internal drainage
◦ Cystogastrostomy
◦ Cystojejunostomy
 Permanent resolution confirmed in b/w 91%–97% of
patients*
◦ Cystoduodenostomy
 Can be complicated by duodenal fistula and bleeding at
anastomotic site

35.  The interface b/w the cyst and the enteric
lumen must be ≥ 5 cm for adequate drainage
 Approaches
◦ Pancreatitis 2 to biliary etiology extra luminal
approach with concurrent laparoscopic
cholecystectomy
◦ Non-biliary origin intraluminal (combined
laparoscopic/endoscopic) approach.

36.  Surgical drainage is the traditional approach –
gold standard.
 Percutaneous catheter drainage – high chance
of persistent pancreatic fistula.
 Endoscopic drainage - less invasive,
becoming more popular, technically
demanding
 .Surgery necessary in complicated
pseudocyts, failed nonsurgical, and multiple
pseudocysts.

37.  Procedure Performed : Cystogastrosotmy
 Operative Finding : Large cyst arising from
pancreas displacing and compressing the
stomach inferiorly.
 Recovery : Smooth