Thursday, January 5, 2017

Step 2 CK: Pancreatic pseudocyst notes

Pancreatic pseudocyst

How does it develop?
A pseudocyst is a collection of pancreatic fluid surrounded by a wall without epithelium. It results from pancreatic injury such as pancreatitis or trauma (seat belt trauma), which essentially disrupts a pancreatic duct. The pancreatic enzymatic fluid that leaks out is contained by surrounding fibrotic tissue.

Although this most commonly appears in patients with chronic pancreatitis, it can also occur in the weeks following resolution of an acute pancreatitis. (It takes 4 to 8 weeks to develop)

How does it present?

Persistent pain, early satiety, nausea, weight loss, and elevated pancreatic enzyme levels in plasma.

How do you diagnose it?'

CT or MRI (Also, high amylase level with the absence of mucin and low carcinoembryonic antigen levels.)

When do you do FNA?

EUS with FNA is indicated for patients in whom the diagnosis of pancreatic pseudocyst is not clear.

When do you observe the patient?

Observation is indicated for asymptomatic patients because spontaneous regression is seen in up to 70% of cases (This is particularly true for patients with pseudocysts smaller than 4 cm in diameter, located in the tail, and no evidence of pancreatic duct obstruction or communication with the main pancreatic duct.)

When do you treat? 

If it persists beyond 6 weeks, or is > 6 cm, or symptomatic (pain, bloating, poor digestion of food), or when the differentiation between a cystic neoplasm and pseudocyst is not possible.

(From UpToDate:)

For patients who require drainage, options include surgical drainage, endoscopic drainage, and percutaneous drainage. If a pseudoaneurysm is present within the fluid collection, it should be embolized prior to drainage of the fluid collection.

In centers with the appropriate expertise, pancreatic fluid collections that abut the stomach or duodenum are often approached via an endoscopic approach, reserving surgical drainage procedures for endoscopic failures, for recurrence following successful endoscopic drainage, or for those not meeting criteria for endoscopic or percutaneous drainage.

That's all!

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