Our clinical experience with management of Pseudocyst of Pancreas

1. CASE SERIES OF PSEUDOCYST OF
PANCREAS
STANLEY MEDICAL COLLEGE & HOSPITAL,CHENNAI

3. Authors
 Prof.Dr.D.Nagarajan
 Dr.G.Venkatesh
 Dr.S.Jim Jebakumar
 Dr.K.Gautham
 Dr.E.Kaushik Kumar, (MS Final Year PG)

4. குறள் 414:
கற்றில னாயினுங் ககட்க அஃத ாருவற்கு
ஒற்கத் ின் ஊற்றாந் துணை.
. உரை:
நூல்கணைக் கற்றவில்ணலயாயினும், கற்றறிந் வர்கைிடம்
ககட்டறிய கவண்டும், அது ஒருவனுக்கு வாழ்க்ணகயில்
ைர்ச்சி வந் க ாது ஊன்றுககால் க ால் துணையாகும்..

5.  Chronic Collection of amylase-rich fluid enclosed in a non-
epitheliazed wall of fibrous(collagen) or granulation tissue.
 Follow after
 Acute Pancreatitis(5-15%)
 Chronic Pancreatitis(20-38%)
 Trauma
 4- 8 weeks from the onset of AP
 Single or multiple or multilobulated

6.  Duct leak
 Intrapancreatic or extend beyond into other cavities or
compartments
 Regress spontaneously 50%
 Chronic pseudocysts may persist
 Thick-walled or large (over 6 cm in diameter)
 Lasted for a long time (over 12 weeks)
 Arisen in the context of chronic pancreatitis

7. Symptoms
Pain
Satiety
Loss of
Weight
Fullness

8. Complications
Abscess /systemic sepsis
Intracystic
hemorrhage/pseudoaneurys
ms
SMV/PV thrombosis
Peritonitis/intraperitoneal
bleeding
Pancreatico pleural fistula Pressure effects

9. US,CT
- Identification of
pseudocyst and
differentiates from
abscess
EUS- Guided FNA
Differentiates
between chronic
pseudocyst and cystic
neoplasms
ERCP/MRCP
ductal
communication,ductal
anomalies, chronic
pancreatitis,plan treatment

10.  Amylase- Level usually high in pseudocysts, but
occasionally in tumours
 Cytology- Inflammatory cells in pseudocyst
 CA 19-9,CEA and MUCIN – negative

11. Intervention
INDICATIONS
Symptoms
If complications
develop
Distinction has to
be made between
a pseudocyst and
a tumour
OPTIONS
Endoscopic
Percutaneous
Surgical
Symptomatic, failure with conservative treatment, persistence over 4 weeks or longer

12. Endoscopic Surgical
 Distance of pseudocyst to the
gastrointestinal wall <1 cm
 Size>5 cm, gut compression, single
cyst, mature cyst, no disconnected
segment of pancreatic duct
Complications
Drainage internally
Stomach
Duodenum
Jejunum
Recurrence <5%

13. Newer techniques
 Forward-viewing echoendoscope
 PFC puncture devices
 Combination devices
 Devices for maintenance of cystenterostomy
 Multiple transluminal gateway technique (MTGT)

14. Case 1
 36 year female presented with complaints of yellowish discolouration of
eyes, high coloured urine,pale stools for 1 month associated with upper
abdominal discomfort and intense itching. No vomiting/ugi bleed. H/o
treatment for Acute Pancreatitis 6 months before. No addictive habits.
No other contributory history. O/e Icteric,non-tender epigastric mass of
size 8 x 6 cm extending to right hypochondrium, smooth surface,firm in
consistency,no movement with respiration. No free fluid and other
systems were normal.
 Transabdominal USG revealed a pseudocyst from head of pancreas
compressing the CBD causing dilation of CBD and IHBR. CECT - 7.3 x 6.7 x
5.1 cm pseudocyst from head of pancreas compressing the CBD(1.2cm).
TBR-6.3mg%. SAP- 517 IU/L. Coagulation profile-Normal.
 UGI Scopy- Normal

15. Patient was taken up for surgery and a Roux loop
Cystojejunostomy was done which relieved the
biliary compression. Post operatively the total
bilirubin was 3.2 on POD 4 and subsequently
returned to normal level. Cyst fluid amylase
was 1210 IU and cytology negative for malignant
cells. Cyst wall HPE – Inflammatory tissue. Patient
was relieved of symptoms and no post operative
complications. Review
USG after 2 months, no radiologically detectable
pseudocyst.

16. Case 2
 A 32-year-old male was admitted with complaints of upper abdominal pain and jaundice of 3 months duration. A history of a
passage of clay-colored stools and high-colored urine was present. The patient gave a history of acute abdominal pain
following a binge of alcohol 6 months ago which was managed conservatively. On examination he was icteric and pruritic
marks were present all over the body. Abdominal examination revealed an epigastric mass of size 7*6 cm, which was firm in
consistency, had the upper border not made out, and which did not move with respiration. The liver was enlarged and
palpable 3 cm below the right costal margin. A liver function test showed elevated serum bilirubin of 16 mg/dL (normal < 1
mg/dL), the direct component being 14 mg/dL (< 0.8 mg/dL), and serum alkaline phosphatase was 206 IU/L (normal value
20–140 IU/L). CA 19-9 was within normal limits (less than 10 IU/Ml.Recently diagnosed DM started on Insulin
 USG abdomen - 8*7cm hypoechoic lesion arising from the head of the pancreas with dilatation of the intrahepatic and
extrahepatic biliary tree. The common bile duct (CBD) measured 1.1 cm in diameter. Cholelithiasis was also seen.
 MRCP and CECT-confirmed the USG findings of a pseudocyst arising from the head of the pancreas compressing the distal
CBD, causing dilatation of biliary radicles
 CECT showed additional features of chronic calcific pancreatitis involving the body and tail of the pancreas.
 UGIendoscopy - normal gastric and duodenal mucosa with extraneous compression of the antropyloric region of the stomach
and duodenum.

17.  After optimizing the general condition of the
patient and achieving glycemic control, he was
taken up for surgery. Intra-operative findings
concurred with the imaging studies. In view of
the proximity of the cyst to the duodenum,
cystoduodenostomy was done.
Cholecystectomy was done and an
intraoperative cholangiogram performed via the
cystic duct showed a stricture in the terminal
common bile duct. A choledocho-
pseudocystostomy was performed for biliary
drainage
 The post-operative period was uneventful, with
the patient becoming clinically anicteric after 10
days and biochemical parameters normalizing
after 25 days. Hpe of the cyst wall was negative
for malignancy The patient has been on follow-
up for 16 months with no specific complaints.
Follow-up USG showed no residual pseudocyst
and a normal intra- and extrahepatic biliary
tree.

18. Case 3
 48 year male chronic alcoholic presented with complaints of fullness in upper abdomen for 4
months. No h/o fever/ vomiting/jaundice/bowel/bladder disturbances. H/o anorexia and
weight loss +. H/o three episodes of acute pancreatitis conservatively managed since 4 years.
Stopped alcohol after the second episode. No h/o exocrine pancreatic insufficiency. Recently
diagnosed DM on OHAs. On examination, thin built and ill nourished,anicteric,flat abdomen,
firm to hard non tender, oval mass of size 6 x 5 cm in epigastrium,not moving with respiration
with restricted mobility. Other systems normal.
 Blood parameters and amylase,lipase and LFT normal range.Ca 19-9 – 12 IU
 Transabdominal USG – 4.3 x 5 cm cystic lesion in body of pancreas with altered echoes.
 MRCP- ? Chronic Pseudocyst of pancreas. ? IPMN of pancreatic body. No e/o calcifications in
parenchyma or ductal system.
 Usg guided FNAC- No e/o tumour cells in the material studied.
 UGI Scopy- pan gastritis

19.  Surgery- Roux loop Cysto-Jejunostomy
 Follow up- HPE- Chronic Inflammatory
cells.
 Cyst Fluid- Amylase- 774 IU
 6 months after surgery – no
radiologically detectable cyst.

20. Case 4
 54year male non alcoholic presented with complaints of pain in upper left quadrant of
abdomen radiating to back for 6 months. No h/of fever /vomiting/ jaundice/bowel/bladder
disturbances. No H/o anorexia and weight loss . H/o one episode of acute pancreatitis
conservatively managed before 7 months. No addictive habits. On examination,anicteric,no
pallor, upper abdomen fullness +. Tenderness + epigastrium and left hypochondrium. Ill
defined mass occupying the above quadrants,no organomegaly/freefluid.Other systems
normal.
 Blood parameters and amylase,lipase and LFT normal range.
 Transabdominal USG – 8.6 x 6.4 cm cystic lesion in tail of pancreas abutting the spleen.
Another cyst of size 3.2 x 2.2 cm in body of pancreas. ? Pseudocyst ? Cystic neoplasm
 MRCP- Pseudocyst of pancreas in body and tail abutting spleen. To r/o Cystic neoplasm.
 Usg guided FNAC- No e/o tumour cells in the material studied.
 UGI Scopy- ulcer + pre pyloric region. HPE- Chronic non-specific inflammation

21.  Surgery – Roux loop cystojejunostomy
 Follow up- HPE- non specific Inflammatory cells.
 Cyst Fluid- Amylase- 1564 IU
 3 months after surgery – symptomatic relief,
radiologically cyst not seen in tail of pancreas. 2 x
2cm seen in body of pancreas.

22. Case 5
 32 year male chronic alcoholic presented with complaints of acute onset
epigastric pain for 2 days. H/o fever & vomiting +.No h/o
jaundice/bowel/bladder disturbances. H/o anorexia +. Last binge of
alcohol 1 day before admission.On examination, moderately built and
nourished,anicteric,tachypnoeic,tachycardic,flat abdomen,upper
abdomen movement reduced with respiration,epigatric tenderness and
guarding +.BS sluggish. . Other systems normal.
 CXR – No e/o hollow viscus perforation.
 Amylase – 2150 IU, Lipase – 983 IU .LFT normal range.
 Transabdominal USG – bulky edematous pancreas with surrounding fat
stranding and fluid collection.
 CECT Abdomen- F/s/o Acute Pancreatitis with Acute fluid collection and
minimal left pleural effusion.
 UGI Scopy- erosive antral gastritis

23.  Patient managed as acute moderate pancreatitis
conservatively.
 After 1 month patient reported with complaints of
abdominal discomfort and difficulty in breathing on
exertion. No h/o fever or vomiting. On examination,
epigastric fullness +. 10 x 6 cm smooth surfaced,firm
non-tender mass occupying epigastrium,right and left
hypochondrium. Left base breath sounds were
absent.

24.  Trans abdominal ultrasound – Pseudocyst of pancreas occupying body and tail with left pleural effusion and
ascites
 Cect abdomen - Pseudocyst of pancreas occupying body and tail with left pleural effusion and ascites. Wall
thickness 4mm.
 Conservatively managed. 6 weeks after- cyst size reduced to 4 x 3 cm.

25. Case 6
 26 year male presented with Abdominal pain for 2 weeks-Acute
onset,Epigastrium to start with later became diffuse,Continuous,pricking
pain,radiating to back,relieved by leaning forward and with medications.H/o
non-bilious vomiting immediately after food intake + for the past one week.H/o
constipation + x 3 days. H/o yellowish discolouration of sclera with passage of
high coloured urine and clay coloured stools x 4 days +. No h/o fever
/pruritus/abdominal distension/recent loss of weight/loss of appetite.H/o
intermittent epigastric pain x 3 months. No comorbidities. Chronic Alcoholism x
3 yrs >360ml/day-last drink 8 days back
 Not Anaemic,Deeply Icteric,No clubbing,No Generalised Lymphadenopathy,No
Pedal Edema
 Examination of Abdomen- Abdomen flat, Tenderness + Epigastrium,Right
Hypochondrium,No guarding/rigidity,No obliteration of liver dullness,No
mass/organomegaly,No free fluid,Murphys sign –ve.

26.  Ultrasound Abdomen: Normal study
 UGI SCOPY: Pangastritis/Erosive Antral
Gastritis,Bulbar healed duodenal
lesions.Submucosal lesion at D2 entry with luminal
obstruction ?Pseudocyst causing duodenal
obstruction.
 SVS: Extrinsic compression at the level of D2,scope
not passed beyond
 CECT ABDOMEN: Possibility of stricture at the
junction of 3rd and 4th part duodenum causing
luminal obstruction
 MRCP: ?Intramural Pseudocyst in the submucosal
layer of Duodenum at the junction of D2,D3
 Patient was managed conservatively and clinically
improved.
 Follow up serial radiological investigations showed
gradual regression and disappearance after 12
weeks

27. Conclusion
 Due to progress in sensitivity and more widespread availability of diagnostic
imaging techniques, the incidence of pancreatic pseudocysts seems to be
increasing steadily. .
 In the above series the different presentations of pseudocyst of pancreas and the
different techniques of management was elaborated
 The majority of these cysts are asymptomatic, and the decision whether or not to
operate is not always straightforward
 The apparent question is how to proceed after the detection of an asymptomatic
pancreatic cyst choosing one of the following options: no further investigations,
additional imaging ± fine needle aspiration (FNA), surveillance, or
surgical/endoscopic treatment.
 Intervention is contemplated if the patient has Symptoms,if complications develop
or a distinction has to be made between a pseudocyst and a tumour

28. References
 Sabiston textbook of surgery,19th edition
 Schwartz’s Principles of surgery,9th edition
 Novel Technique in the Management of Obstructive Jaundice Caused by
Pancreatic Pseudocyst , Archives of ClinicalExperimental Surgery,Gautham
Krishnamurthy, Venkatesh Gottumukala, A Rajendran, P Darwin
 www.giejournal.org ,GASTROINTESTINAL ENDOSCOPY Volume 77, No. 6 : 2013
 World J Gastroenterol 2009 January 7; 15(1): 38-47 wjg@wjgnet.com World
Journal of Gastroenterology ISSN 1007-9327
 Pancreatic pseudocysts (Part I)Article by John Baillie, MB, ChB, FRCP,Durham,
North Carolina