Pancreatic Pseudocyst

Excerpt

A true cyst is a localized fluid collection that is contained within an epithelial lined capsule. In contrast, a pseudocyst is a fluid collection that is surrounded by a non-epithelialized wall made up of fibrous and granulation tissue, hence the name “pseudo” cyst. A pancreatic pseudocyst is an encapsulated collection of homogenous fluid with little or no necrotic tissue within it. It is usually well circumscribed and located outside of the pancreas, often in the lesser sac. Pancreatic pseudocysts are often seen as a complication of chronic pancreatitis and less commonly from acute pancreatitis. They occur when the damage of the pancreatic ducts, frequently from biliary stones or alcohol, causes extravasation and collection of the pancreatic fluid. Regardless of the cause, the overall incidence of pseudocysts is low; 0.5 to 1 per 100,000 adults per year.

Symptoms of pseudocysts are typically non-specific and may present only with vague abdominal pain, nausea, or vomiting. However, a history of preceding acute or chronic pancreatitis in conjunction with classic imaging findings of a thick-walled, well defined, fluid-filled mass next to the pancreas is almost certainly pathognomic of a pancreatic pseudocyst. A contrast-enhanced CT scan of the abdomen is the diagnostic modality of choice. Most pseudocysts resolve spontaneously, and treatment is usually conservative with supportive care. In general, larger cysts are more likely to become symptomatic or cause complications. The chronicity of symptoms often correlates with the need for more involved care. Examples of potential complications include infection, hemorrhage, pseudocyst rupture, and disruptions of the pancreatic duct system. To identify these complications early and minimize their morbidity, routine follow up visits are recommended. Close monitoring of the size of the cyst with interval imaging is also important for early identification of complications. Unfortunately, the specific time intervals to obtain follow up imaging are not universally standardized.

In the event that symptoms worsen or complications occur, there are multiple procedure-oriented treatment options available. Percutaneous drainage can be offered for individuals who cannot tolerate more invasive interventions. On the other hand, endoscopic procedures, especially after the introduction of endoscopic ultrasound (EUS), has been gaining popularity. Finally, the gold standard of surgical drainage has proven its efficacy, especially in large and complicated pseudocysts. The treatment of choice depends on the individual patient profile. It is essential to understand the risks and benefits associated with each treatment modality. It is also important to involve an interprofessional team in more complicated cases, which may include internists, endoscopists, interventional radiologists, and surgeons to ensure the best possible clinical outcome.

In this article, we will discuss the etiology, pathogenesis, clinical features, evaluation, management, and role of interdisciplinary teams in managing this intriguing disease.