Pancreatic pseudocyst

1. SURGERY GRAND ROUND
PRESENTED BY
NAJEEB NIZAR (MBChB 6)

2. CASE STUDY
• A 40 y/o male who came in 2 weeks ago with
a one and a half month history of abdominal
pain at the left hypochondrial region. The pain
was sudden in onset and sharp.. It radiates to
the back and the right hypochondrial region. It
is severe at night. It is exacerbated by eating
food and being seated upright. It is relieved by
painkillers. Patient had one episode of loss of
consciousness due to the pain

3. Cont’d
• No history of trauma
• Constitutional symptoms absent apart from decreased
appetite.
• No history of vomiting, diarrhoea
• Past medical- admitted on 5/8/21 due to the same
problem. Was discharged on pain meds. The rest of the
medical history is non-remarkable
• Social
– Smoker with a 1 year pack history
– Alcohol consumption of 2 bottles/day of spirits
such as vodka for 15 years
• R.O.S- Non-remarkable

4. Cont’d
• General exam
– Pt was in a fair general condition; not wasted
– (JACCLWOD)
– Vitals BP 102/71 mmHg (normal), PR 132/min
(increased), Temp 36.7C, RR 19/min
• P/A
– Inspection- No obvious scars. Umbilicus inverted.
Obvious abdominal distension from the epigastric
region to the level of umbilicus. Cullen sign
negative. Grey Turner sign negative

5. Cont’d
– Palpation- Palpable mass at the epigastric region
that is tender. The mass was firm and fixed. It was
multinodular. Edges of the mass were not
palpated. The mass was non-pulsatile. Rovsing
sign negative. Psoas sign negative. Murphy sign
negative. No hepatomegaly, no splenomegaly
– Percussion- Dullness was elicited in the epigastric
and the umbilical region. It wasn’t shifting. The
rest of the abdomen was tympanic
– Auscultation- Bowel sounds were present at a rate
of 15/min (normal). No bruits heard.

6. Cont’d
• Other systems were non-remarkable
• DRE was non-remarkable
• Ix- FHG- normal, RFTs- creatinine decreased,
uric acid increased LFTs- albumin decreased,
GGT high, total protein high, RBS- 4.6mmol/L
• DDx?

7. DDx
• Pancreatitis (r/o through cullen and grey turner
negative)
• Appendicitis (r/o using Rovsing negative, Psoas
sign negative, no neutrophil shift to the left)
• Perforated duodenal ulcer (r/o since no
hematemesis)
• Cholecystitis (r/o since patient doesn’t have
jaundice, Murphy sign negative)
• Cholelithiasis (r/o because 5 F’s absent; fat, forty,
female, fair and fertile)

8. DDx
• Ca head of pancreas (r/i because of a mass at
the epigastric region)
• Acute liver disease (r/o since there’s no
hepatomegaly, no jaundice)
• Gastric adenocarcinoma (r/i because of mass
at epigastric region)
• Hepatocellular carcinoma (r/o because no
bruit heard upon auscultation of the liver)

9. DDx
• Alcoholic steatohepatitis (r/o due to absence of
jaundice)
• Diverticulitis (r/o because of the left hypochondrial
region pain, diverticulitis commonly occurs at left iliac
region)
• Urinary tract Infection (r/o since there’s no dysuria,
increased frequency)
• Ruptured abdominal aortic aneurysm (r/o because
patient had stable BP)
• Ca of the transverse colon
• Pancreatic pseudocyst (rare, but this is what our pt
had)

10. PANCREATIC PSEUDOCYST

11. Anatomy

12. Definition
• Pancreatic pseudocyst is best defined as localized
fluid collections that are rich in amylase, lipase
and trypsin
• It has a non-epithilialized wall consisting of
fibrous and granulation tissue
• Usually appears several weeks after the onset of
pancreatitis.
• Rarely, chronic pancreatitis and trauma can cause
pseudocysts
• Usually located at the lesser peritoneal sac in
proximity to pancreas

13. Epidemiology
• Occurs commonly in the males
• May occur after pancreatitis in any age group
• In elderly, care should be taken not to confuse
cystic neoplasms with pseudocysts

14. Aetiology
• 75-85% of cases are caused by alcohol or
gallstone-related pancreatitis
• In children, trauma and pseudocysts have a
high correlation
• Other causes include drug toxicity
(sulphonamides, CPZ, Tetracyclines)

15. Pathophysiology
• Pancreatic ductal disruption secondary to:
– Acute pancreatitis
– Chronic pancreatitis
– Trauma
– Ductal obstruction and pancreatic neoplasms

16. Pathophysiology
• Acute pancreatitis
– It causes ductular disruption, resulting in leakage
of pancreatic juice from inflammed area of gland,
accumulating in the space adjacent to the
pancreas
– Inflammatory response induces formation of
distinct cyst wall composed of granulation tissue,
and fibrosis

17. Pathophysiology
• Chronic pancreatitis
– Pancreatic duct is chronically obstructed
– Ongoing proximal pancreatic secretion leads to
secular dilation of duct leading to true retention
cyst
– Formed microcysts can eventually coalesce and
lose their epithelial lining as they enlarge

19. History
• No specific set of symptoms that are
pathognomonic
• Consider the possibility of pseudocyst in a patient
who has had:
– Persistent abdominal pain
– Anorexia
– Abdominal mass after an episode of pancreatitis
– Pleural effusion
– Rarely, jaundice and sepsis (from infected pseudocyst)

20. Examination
• Tender abdomen
• Palpable mass in the abdomen
• Scleral icterus
• Pleural effusion
• Peritoneal signs suggest rupture of cyst
– Guarding
– Rebound tenderness
– Fever

21. Investigations
• Labs
– Baseline FHG, U/E/C’s, RBS, GXM
– Serum amylase, serum lipase elevated
– bilirubin and LFT’s elevated if biliary tree involved
How to differentiate tumour from pseudocyst
Tumour Pseudocyst
Carcinoembryonic
antigen
Elevated (greater
than 400ng/mL)
Low
Fluid viscosity Elevated Low
Amylase Low Elevated
Cytology Usually positive Usually negative

22. Investigations
• Radiological
– Abdominal CT- Gold standard. The usual finding is a
large cyst cavity in and around the pancreas. Multiple
cysts may be present. The pancreas may have
calcifications
– Abdominal U/S- may visualize cystic fluid collections in
and around the pancreas.
– Endoscopic U/S- helpful in detecting small portal
collaterals from otherwise undetected portal
hypertension that may increase bleeding risk with
transmural drainage

23. Investigations
• Radiological cont’d
– ERCP
– MRI
• Histology

24. CT scan Pancreatic pseudocyst (yellow
circle) compressing on the stomach
(yellow arrow)

25. 2/3 of pancreatic pseudocysts occur at
tail of pancreas showing hypoechoicity

26. Management
• Goal of therapy is to avoid complications
• Most pseudocysts resolve without
interference and require supportive care
• Indications for surgical drainage:
– Complications (discussed at the end of the
presentation)
– Symptoms such as abdominal pain, vomiting,
abdominal distension
– Concern about possible malignancy

27. Surgical care
• Four types of drainage:
– Catheter drainage
– Transpapillary drainage
– Transmural drainage
– Surgical drainage

28. Surgical care
• Catheter drainage- Percutaneous catheter
placement is the procedure of choice for
treating infected pseudocysts. It is
contraindicated in patients who are poorly
compliant and cannot manage a catheter at
home. It is also contraindicated in patients
with strictures of main pancreatic duct.
Octreotide (somatostatin analogue) can be
used as an adjunct to catheter drainage to
reduce pancreatic exocrine function

29. Surgical care
• Transpapillary drainage- done via ERCP. It requires
cyst communication with the pancreatic duct
• Transmural drainage- This involves performing an
endoscopy and finding a bulge into the lumen of
the stomach or duodenum. The bulge is usually
caused by compression of the cyst. Access gained
to the cyst by cutting the wall of the
stomach/duodenum using a knife and then
placing a stent.

30. Surgical care
• Surgical drainage- It is the criterion standard
against which all therapies are measured. Internal
drainage is the procedure of choice. The type of
procedure depends on location of cyst:
– Cystogastrostomy- This is a surgery to create an
opening between a pancreatic pseudocyst and the
stomach when the cyst is in a suitable position to be
drained into the stomach. This conserves pancreatic
juices that would otherwise be lost. This was what
was done on the patient in the case study

31. – Cystojejunostomy- a connection is created
between the cyst and the jejunum so that the cyst
fluid is drained directly into the small intestine
– Cystoduodenostomy- A connection is created
between duodenum and the cyst to allow
drainage of fluid into the duodenum

33. Complications
• Infection
• Hemorrhage- especially when the pseudocyst
injures the blood vessels
• Obstruction- blockage of the bile duct, duodenum
• Rupture- leading to peritonitis
• Thrombosis (most common is the splenic vein)
• Pseudoaneurysm formation (splenic artery most
common)