Pseudocyst

A patient with acute pancreatitis may develop many severe local and systemic complications. Local complications involve fluid collection, necrosis, or abscess in the pancreas. A pancreatic fluid collection (or pancreatic pseudocyst) is a collection of tissue, pancreatic enzymes, and blood that forms weeks after acute pancreatitis. Many pancreatic pseudocysts resolve spontaneously, but some require surgical drainage.5 Rupture of a pancreatic pseudocyst with associated erosion and hemorrhage of major abdominal blood vessels can have a mortality approaching 60% thus, continued monitoring of a pseudocyst is prudent.6... 

Pancreatic abscess is a collection of pus that forms in the pancreas 4 to 6 weeks after acute pancreatitis. Pancreatic abscess is usually less life-threatening than pancreatic necrosis or pancreatic pseudocyst and can be managed with percutaneous drainage.5... 

The goals of treatment for acute pancreatitis include (1) resolution of nausea, vomiting, abdominal pain, and fever (2) ability to tolerate oral intake (3) normalization of serum amylase, lipase, and white blood cell count and (4) resolution of abscess, pseudocyst, or fluid collection as measured by CT scan. 

Local complications in severe AP may include acute fluid collection, pancreatic necrosis, abscess, pseudocyst formation, and pancreatic ascites. 

Removal of biliary tract gallstones with endoscopic retrograde cholangiopancreatography or surgery usually resolves AP and reduces the risk of recurrence. Surgery may be indicated in AP to treat pseudocyst, pancreatic abscess, and to drain the pancreatic bed if hemorrhagic or necrotic material is present. 

Malabsorption of protein and fat occurs when the capacity for enzyme secretion is reduced by 90%. A minority of patients develop complications including pancreatic pseudocyst, abscess, and ascites or common bile duct obstruction leading to cholangitis or secondary biliary cirrhosis. 

Serum amylase and lipase concentrations usually remain normal unless the pancreatic duct is blocked or a pseudocyst is present. 

A 55-year-old woman with a history of chronic pancreatitis developed epigastric pain and melena and was found to have a splenic artery pseudoaneurysm expanding a pseudocyst. She was given an intravenous bolus of octreotide followed by an infusion of 50 micrograms/ hour. A CT scan subsequently suggested thrombosis of the pseudoaneurysm, with segmental splenic infarction. Nine months later the pseudoaneurysm had recanalized. 

Physical examination of the abdomen reveals tenderness most marked in the epigastrium but sometimes present throughout. Bowel sounds are decreased or absent. Usually there are no masses palpable their presence most often indicates complications of AP, such as a pseudocyst or an abscess. In necrotizing pancreatitis the abdomen may be distended due to the intraperitoneal collection of fluid. The temperature is usually slightly elevated (100-101°F) in uncomplicated cases. Physical examination may reveal pleural effusion, especially on the left side. 

Severe acute pancreatitis Acute pancreatitis associated with organ failure and/or local complications, such as necrosis, abscess, or pseudocyst. 

Acute pseudocyst A collection of pancreatic juice enclosed by a wall of fibrous or granulation tissue, which arises as a consequence of acute pancreatitis, pancreatic trauma, or chronic pancreatitis. 

W5. Warshaw, A. L., and Lee, K. H., Aging changes of pancreatic isoamylases and the appearance of old amylase in the serum of patients with pancreatic pseudocysts. Gastroenterology 79, 1246-1251 (1980). 

Pancreatitis is a significant problem in patients undergoing 1-ASP therapy. The reported incidence ranges from 8 to 18%, the mortality from 1.8 to 4.6% [121-123]. It may develop up to 16 weeks after treatment. Rarely, pancreatic pseudocysts have been reported. 

Ramer, M., Diznoff, S.B., Hewes, A.C. Intrasplenic pancreatic pseudocyst another cause of splenomegaly Clin. Radiol. 1974 25 525-529... 

Reynolds, M., Donaldson, J.S., Vogelzar, R.L. Giant iatrogenic splenic pseudocyst. J. Pediatr. Surg. 1989 24 700-701... 

Unger, P., Moran, R.M. Ascitic pseudocyst obstructing superior vena cava as a complication of a peritoneo-venous shunt. Gastroenterology 1981 81 1137-1139... 

Fig. 25.22 Echinococcus alveolaris hydatid pseudocyst surrounded by a rim of radially arranged histiocytes. Markedly damaged adjacent liver parenchyma. Small parasitic membranes in the bright lumen of the pseudocyst (arrow) (HE)...

Congenital anomalies and aneurysms in the hepatic arteries are very rare. (129) Acquired aneurysms are the result of vessel wall damage, injuries or inflammatory processes. (I3l, 133, 136) Pseudoaneurysms may occur after acute pancreatitis and the formation of pseudocysts. (135) (s. tab. 39.5)... 

Pancreatitis has been reported in up to 16% of children receiving asparaginase for a variety of neoplasms (13). Pseudocyst formation has been described (14). 

Bertolone SJ, Fuenfer MM, Groff DB, Patel CC. Delayed pancreatic pseudocyst formations. Long-term comphcation of L-asparaginase treatment. Cancer 1982 50(12) 2964-6. 

There have been over 50 published reports of acute pancreatitis associated with valproate (SEDA-18, 70) (84), including several confirmed by rechallenge. Deaths have occurred from hemorrhagic pancreatic necrosis complications can include pleural and pericardial effusions, coagulopathy, pseudocyst, ascites, wound infection, and pneumonia (SED-13, 151) (85). Hepatotoxicity can coexist. There is suggestive evidence that end-stage renal insufficiency (SEDA-22, 92) and mental retardation (84) can be predisposing factors. 

FIGURE 31-3. Abdominal ultrasound demonstrating a chronic pancreatic pseudocyst (arrows). 

FIGURE 31-4. CT scan of the abdomen showing pancreatitis with calcification white arrow) and pancreatic pseudocyst black arrows). 

FIGURE 31-8. ERCP demonstrating a dilated, irregular pancreatic duct with areas of stricturing large arrow). A pancreatic pseudocyst is visible immediately adjacent to the spine (small arrows). 

Local complications—including acute fluid collection, pancreatic necrosis, abscess, and pseudocyst (collection of pancreatic juice and tissue debris enclosed by a wall of fibrous or granulation tissue)— develop about 4 to 6 weeks after the initial attack. Pancreatic abscess is usually a secondary infection of necrotic tissue or pseudocysts and correlates with the severity of the pancreatitis. Most deaths result from... 

Complications, including pancreatic pseudocysts, pleural effusions, and ascites, may be detected on physical examination. 

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