Pancreatic Pseudocysts

Intro & Etiology - Cystic Conundrum

• Definition: Localized fluid collection (amylase-rich) near pancreas, enclosed by a non-epithelialized, fibrous, or granulation tissue wall.
• Lacks true epithelial lining (unlike true cysts).
• Etiology:
  • Acute Pancreatitis: Most common cause.

    ⭐ Most pseudocysts (75-85%) are a sequela of acute pancreatitis.

  • Chronic Pancreatitis: Often due to ductal obstruction.
  • Pancreatic Trauma: Blunt abdominal injury, iatrogenic (post-surgical/ERCP).
  • Pancreatic Neoplasms (rarely).
  • Idiopathic.

Pathophys & Histo - Wall Woes

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Clinical Features & Diagnosis - Tummy Troubles & Tell-Tales

• Symptoms: Often asymptomatic. If present: epigastric pain (radiates to back), nausea, vomiting, early satiety, weight loss. Palpable mass. Jaundice (biliary compression).
• History: Prior pancreatitis or trauma.
• Labs: Amylase/lipase may be ↑ or normal (esp. if chronic, >6 wks). CA 19-9 mildly ↑ possible.
• Imaging:
  • USG: Initial scan for fluid.
  • CECT Abdomen: Confirms (wall forms ~4-6 wks), details size, location, complications (infection, hemorrhage).
  • MRI/MRCP: If CECT unclear or for ductal anatomy.
  • EUS+FNA: Complex cases/rule out neoplasm (fluid: ↑ amylase, low CEA).

⭐ CECT abdomen is the gold standard for diagnosing pancreatic pseudocysts (mature wall visible after 4-6 weeks) and assessing complications.

Complications & Management - Perilous Pockets & Plans

• Key Complications:
  • Infection (abscess formation), hemorrhage (e.g., from pseudoaneurysm).
  • Rupture (peritonitis), obstruction (gastric, biliary), persistent severe pain.
• Management Strategy:
  • Conservative: Watchful waiting if asymptomatic, <6cm, AND <6wks old.

    ⭐ Spontaneous resolution in up to 50% of pseudocysts, especially if <6cm and asymptomatic; watchful waiting is often the initial approach.

  • Intervention indicated if: Symptomatic, size >6cm, duration >6wks, or complications present.
    • Endoscopic drainage (cystogastrostomy/duodenostomy) is first-line.
    • Percutaneous drainage: Alternative, especially for infected pseudocysts.
    • Surgical drainage (e.g., cystojejunostomy): Reserved for failures or specific anatomical challenges.

High‑Yield Points - ⚡ Biggest Takeaways

• Most common pancreatic cystic lesion, often a sequela of acute/chronic pancreatitis or trauma.
• Distinctive feature: lacks a true epithelial lining; wall is fibrous and granulation tissue.
• Typically peripancreatic, frequently located in the lesser sac.
• Fluid analysis reveals markedly elevated amylase and lipase levels.
• CT scan is the primary diagnostic imaging modality.
• Major complications: infection, hemorrhage, rupture, pseudoaneurysm.
• Management: observation for asymptomatic cases; drainage if symptomatic, large (>6cm), or complicated.