Pseudocyst

Has mucous lining epithelium REF: Harrison 16^th e p. 1901

• Pseudopancreatic cyst is not a true cyst and its wall doesn’t have an epithelial lining.
• Wall consists of necrotic tissue, granulation tissue and fibrous tissue.
• It presents as an epigastric mass.

Conservative REF: Sabiston 18th ed chapter 56

Recent reports have shown that many pseudocysts eventually resolve without complications. Intervention is not mandatory in all cases unless the pseudocysts are

1. Symptomatic
2. Enlarging
3. Associated with complications.

The likelihood that a pseudocyst will resolve spontaneously, however, is dependent on its size. Large pseudocysts (i.e., >6 cm in diameter) are more likely to become symptomatic either because they are tender or because of their mass effect on adjacent organs

Symptomatic or enlarging pseudocysts can be treated by several methods:

• Those in the tail can be treated by excision (i.e., distal pancreatectomy), but excision in the setting of recent acute inflammation may be hazardous.
• Most patients who develop symptomatic pseudocysts are best managed by pseudocyst drainage.
• In poor surgical risk patients, percutaneous catheter drainage can be considered.
• Internal drainage can be accomplished either endoscopically (by transpapillary drainage, cystogastrostomy, or cystoduodenostomy) or surgically (by cystogastrostomy, cystoduodenostomy, or Roux-en-Y cystojejunostomy).
• Pseudocysts that are directly adjacent to either the stomach or duodenum can be safely drained endoscopically if there are no intervening vessels. After endoscopic ultrasound and preliminary aspiration of the cyst fluid to confirm the diagnosis and exclude intervening vessels, endoscopic drainage is achieved by making an incision into the pseudocyst through the wall of the stomach or duodenum.
• Transpapillary drainage might be more appropriate for patients with pancreatic head pseudocysts

A pseudopancreatic cyst is not a true cyst.

It is a chronic collection of pancreatic fluid surrounded by a nonepithelialized wall of granulation tissue and fibrosis. 

It is seen in 10% of patients with acute pancreatitis and 20-30% patients with chronic pancreatitis.

It is the most common complication of chronic pancreatitis.

Pateints usually presents with pain, fullness or early satiety.

Pancreatic pseudocysts mostly occur as a complication of acute and chronic pancreatitis. In children, abdominal trauma is the most common cause.

Pseudocysts are caused by pancreatitis in 90% of cases and by trauma in 10%. Approximately 85% are located in the body or tail of the pancreas. Some patients have two or more pseudocysts. Abdominal pain is the usual presenting complaint.

Reference:
Harrisons Principles of Internal Medicine, 18th Edition, Page 2642

Rupture and hemorrhage are the prime causes of death in pancreatic pseudocyst. A triad : 1. increase in the size of the mass, a localized bruit over the mass, and decrease in hemoglobin level should alert one to the possibility of hemorrhage from a pseudocyst.

Reference:
Harrisons Principles of Internal Medicine, 18th Edition, Page 2642

Ans. is b^‘ i.e., Body

o Pseudocysts of the pancreas are collection of tissue, fluid, debris pancreatic enzymes and blood which develop over a period of time after the onset of acute pancreatitis. These fluids consisting of pancreatic enzymes released due

to disruption of the ductal system.

o In contrast to true cyst, pseudocyst do not have an epithelial lining, their wall consists of necrotic tissue, granulation tissue and fibrous tissue.

o Approximately 85% of pseudocyst are located in the body and tail of pancreas and only 15% of pseudocyst are located in the head of pancreas.

Ans. is ‘b’ i.e., Lining

Ans. is ‘b’ i.e. Pancreatitis

• Most common cause of pancreatic pseudocyst is Pancreatitis (90%) The second most common cause is trauma (10%).
• Pseudocysts are seen in both acute and chronic pancreatitis.

Ans. is ‘d’ ie. USG and follow up 

• Management of Pancreatic Pseudocyst

A pancreatic pseudocyst may resolve spontaneously so it is followed with serial ultrasound studies. Indications of Surgical intervention: (Ref: Bailey and Love 25/e 1145; CSDT 13/e p583; Harrison 17/e p)

i)        Age of cyst more than 12 weeks without resolution

ii)     Size of cyst greater than 6 cm.

iii)    Symptomatic

iv)     Development of complications (eg. haemorrhage, perforation, g.i. obstruction)

But note that these indications for intervention are just a generalization used for teaching the undergraduates. These are not specific indications for interventions.

Therapeutic interventions are advised (irrespective of size and duration) when

– the pseudocyst is symptomatic or

– increasing is size on follow up studies, or

– any complication (rupture, hemorrhage, or abscess) arise or

– there is suspicion of malignancy.

Thus expectant management is adequate (irrespective of size) if the patient is asymptomatic and serial u/s studies show that the cyst is resolving.

• Surgical methods

a)       Internal Drainage – most preferred surgical management in uncomplicated pseudocyst is internal drainage. The three options are

Cystojejunostomy

Cystogastrostomy

Cystoduodenostomy

Internal drainage can be done either open surgical or laparascopic or by percutaneous catheter-based methods (transgastric puncture and stent placement to create a cystogastrostomy)

b)      Excision of Pseudocyst – is hardly done and is usually limited to pseudocyst involving the tail of the pancreas.

c)       External drainage – is done in:‑

–  infected pseudocyst

– for immature pseudocyst with thin nonfibrous walls that does not allow safe internal drainage.

–  in an unstable pt. in whom more complex surgical intervention is precluded.

d) Transpapillary pancreatic duct stent : Because pseudocysts often communicate with the pancreatic ductal system, two newer approaches to pseudocyst management are based on main duct drainage, rather than pseudocyst drainage per se.

A stent is passed into the pseudocyst through the papilla of Vater. this drainage, particularly when incomplete, can allow bacteria to enter the pseudocyst and lead to development of an infected pseudocyst.

Another transpapillary approach involves placing a stent across the duct defect rather than into the cyst through the defect. By excluding pancreatic juice from the pseudocyst, this bridging intraductal stent may permit the duct disruption to heal and the pseudocyst to resolve without drainage (analogous to the use of common bile duct stents in the setting of a cystic duct leak).

Answer is ‘d’ i.e. can present from mediastinum of pubis 

Answer is ‘b’ i.e. Infection

• “Other than pain, infection is the most common complication” – Maingot’s 10/e, p 1929
• Other complications are:

Obstruction of GIT

Hemorrhage

Rupture

Pseudoanetoysm – splenic artery is most frequently involved.

Ans is d i.e. All of the above

Ans. is ‘d’ i.e., Carcinomatous change 

Ans. is ‘c’ i.e., Calcification in the cyst wall

Answer is B (Pancreatitis)

Most common cause of pancreatic pseudocyst is Pancreatitis (90%). The second most common cause is trauma (10%).