CASE SERIES OF PSEUDOCYST OF PANCREAS

STANLEY MEDICAL COLLEGE & HOSPITAL,CHENNAI

Authors

Prof.Dr.D.Nagarajan Dr.G.Venkatesh Dr.S.Jim Jebakumar Dr.K.Gautham

Dr.E.Kaushik Kumar, (MS Final Year PG)

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Chronic Collection of amylase-rich fluid enclosed in a non-epitheliazed wall of fibrous(collagen) or granulation tissue.

Follow after Acute Pancreatitis(5-15%)

Chronic Pancreatitis(20-38%)

Trauma

4- 8 weeks from the onset of AP

Single or multiple or multilobulated

Duct leak Intrapancreatic or extend beyond into other cavities

or compartments Regress spontaneously 50% Chronic pseudocysts may persist

Thick-walled or large (over 6 cm in diameter)

Lasted for a long time (over 12 weeks)

Arisen in the context of chronic pancreatitis

Symptoms

Pain

SatietyLoss of Weight

Fullness

Complications

Abscess /systemic sepsisIntracystic

hemorrhage/pseudoaneurysms

SMV/PV thrombosis

Peritonitis/intraperitoneal bleeding

-US,C

T

- Identificati

on of pseudocyst

and differentiat

es from abscess

EUS- Guided

FNA

Differentiates between

chronic pseudocyst and cystic neoplasms

ERCP/MRCP

ductal communicatio

n,ductal anomalies,

chronic pancreatitis,plan treatment

Amylase- Level usually high in pseudocysts, but occasionally in tumours

Cytology- Inflammatory cells in pseudocyst CA 19-9,CEA and MUCIN – negative

Intervention

INDICATIONS

Symptoms

If complications develop

Distinction has to be made between a pseudocyst and a tumour

Symptomatic, failure with conservative treatment, persistence over 4 weeks or longer

EndoscopicSurgical

Distance of pseudocyst to the gastrointestinal wall <1 cm

Size>5 cm, gut compression, single cyst, mature cyst, no disconnected segment of pancreatic duct

Complications

Drainage internallyStomachDuodenum Jejunum

Recurrence <5%

Newer techniques

Forward-viewing echoendoscope

PFC puncture devices

Combination devices

Devices for maintenance of cystenterostomy

Multiple transluminal gateway technique (MTGT)

Case 1

36 year female presented with complaints of yellowish discolouration of eyes, high coloured urine,pale stools for 1 month associated with upper abdominal discomfort and intense itching. No vomiting/ugi bleed. H/o treatment for Acute Pancreatitis 6 months before. No addictive habits. No other contributory history. O/e Icteric,non-tender epigastric mass of size 8 x 6 cm extending to right hypochondrium, smooth surface,firm in consistency,no movement with respiration. No free fluid and other systems were normal.

Transabdominal USG revealed a pseudocyst from head of pancreas compressing the CBD causing dilation of CBD and IHBR. CECT - 7.3 x 6.7 x 5.1 cm pseudocyst from head of pancreas compressing the CBD(1.2cm). TBR-6.3mg%. SAP- 517 IU/L. Coagulation profile-Normal.

UGI Scopy- Normal

Patient was taken up for surgery and a Roux loop

Cystojejunostomy was done which relieved the

biliary compression. Post operatively the total

bilirubin was 3.2 on POD 4 and subsequently

returned to normal level. Cyst fluid amylase

was 1210 IU and cytology negative for malignant

cells. Cyst wall HPE – Inflammatory tissue. Patient

was relieved of symptoms and no post operative

complications. Review

USG after 2 months, no radiologically detectable

pseudocyst.

Case 2 A 32-year-old male was admitted with complaints of upper abdominal pain and jaundice of 3 months duration. A history of a

passage of clay-colored stools and high-colored urine was present. The patient gave a history of acute abdominal pain following a binge of alcohol 6 months ago which was managed conservatively. On examination he was icteric and pruritic marks were present all over the body. Abdominal examination revealed an epigastric mass of size 7*6 cm, which was firm in consistency, had the upper border not made out, and which did not move with respiration. The liver was enlarged and palpable 3 cm below the right costal margin. A liver function test showed elevated serum bilirubin of 16 mg/dL (normal < 1 mg/dL), the direct component being 14 mg/dL (< 0.8 mg/dL), and serum alkaline phosphatase was 206 IU/L (normal value 20–140 IU/L). CA 19-9 was within normal limits (less than 10 IU/Ml.Recently diagnosed DM started on Insulin

USG abdomen - 8*7cm hypoechoic lesion arising from the head of the pancreas with dilatation of the intrahepatic and extrahepatic biliary tree. The common bile duct (CBD) measured 1.1 cm in diameter. Cholelithiasis was also seen.

MRCP and CECT-confirmed the USG findings of a pseudocyst arising from the head of the pancreas compressing the distal CBD, causing dilatation of biliary radicles

CECT showed additional features of chronic calcific pancreatitis involving the body and tail of the pancreas.

UGIendoscopy - normal gastric and duodenal mucosa with extraneous compression of the antropyloric region of the stomach and duodenum.

After optimizing the general condition of the patient and achieving glycemic control, he was taken up for surgery. Intra-operative findings concurred with the imaging studies. In view of the proximity of the cyst to the duodenum, cystoduodenostomy was done. Cholecystectomy was done and an intraoperative cholangiogram performed via the cystic duct showed a stricture in the terminal common bile duct. A choledocho-pseudocystostomy was performed for biliary drainage

The post-operative period was uneventful, with the patient becoming clinically anicteric after 10 days and biochemical parameters normalizing after 25 days. Hpe of the cyst wall was negative for malignancy The patient has been on follow-up for 16 months with no specific complaints. Follow-up USG showed no residual pseudocyst and a normal intra- and extrahepatic biliary tree.

Case 3 48 year male chronic alcoholic presented with complaints of fullness in upper abdomen for 4

months. No h/o fever/ vomiting/jaundice/bowel/bladder disturbances. H/o anorexia and weight loss +. H/o three episodes of acute pancreatitis conservatively managed since 4 years. Stopped alcohol after the second episode. No h/o exocrine pancreatic insufficiency. Recently diagnosed DM on OHAs. On examination, thin built and ill nourished,anicteric,flat abdomen, firm to hard non tender, oval mass of size 6 x 5 cm in epigastrium,not moving with respiration with restricted mobility. Other systems normal.

Blood parameters and amylase,lipase and LFT normal range.Ca 19-9 – 12 IU Transabdominal USG – 4.3 x 5 cm cystic lesion in body of pancreas with altered echoes. MRCP- ? Chronic Pseudocyst of pancreas. ? IPMN of pancreatic body. No e/o calcifications in

parenchyma or ductal system. Usg guided FNAC- No e/o tumour cells in the material studied. UGI Scopy- pan gastritis

Surgery- Roux loop Cysto-Jejunostomy

Follow up- HPE- Chronic Inflammatory cells.

Cyst Fluid- Amylase- 774 IU

6 months after surgery – no radiologically detectable cyst.

Case 4

54year male non alcoholic presented with complaints of pain in upper left quadrant of abdomen radiating to back for 6 months. No h/of fever /vomiting/ jaundice/bowel/bladder disturbances. No H/o anorexia and weight loss . H/o one episode of acute pancreatitis conservatively managed before 7 months. No addictive habits. On examination,anicteric,no pallor, upper abdomen fullness +. Tenderness + epigastrium and left hypochondrium. Ill defined mass occupying the above quadrants,no organomegaly/freefluid.Other systems normal.

Blood parameters and amylase,lipase and LFT normal range. Transabdominal USG – 8.6 x 6.4 cm cystic lesion in tail of pancreas abutting the spleen.

Another cyst of size 3.2 x 2.2 cm in body of pancreas. ? Pseudocyst ? Cystic neoplasm MRCP- Pseudocyst of pancreas in body and tail abutting spleen. To r/o Cystic

neoplasm. Usg guided FNAC- No e/o tumour cells in the material studied. UGI Scopy- ulcer + pre pyloric region. HPE- Chronic non-specific inflammation

Surgery – Roux loop cystojejunostomy Follow up- HPE- non specific Inflammatory cells. Cyst Fluid- Amylase- 1564 IU 3 months after surgery – symptomatic relief,

radiologically cyst not seen in tail of pancreas. 2 x 2cm seen in body of pancreas.

Case 5 32 year male chronic alcoholic presented with complaints of acute onset

epigastric pain for 2 days. H/o fever & vomiting +.No h/o jaundice/bowel/bladder disturbances. H/o anorexia +. Last binge of alcohol 1 day before admission.On examination, moderately built and nourished,anicteric,tachypnoeic,tachycardic,flat abdomen,upper abdomen movement reduced with respiration,epigatric tenderness and guarding +.BS sluggish. . Other systems normal.

CXR – No e/o hollow viscus perforation. Amylase – 2150 IU, Lipase – 983 IU .LFT normal range. Transabdominal USG – bulky edematous pancreas with surrounding fat

stranding and fluid collection. CECT Abdomen- F/s/o Acute Pancreatitis with Acute fluid collection and

minimal left pleural effusion. UGI Scopy- erosive antral gastritis

Patient managed as acute moderate pancreatitis conservatively.

After 1 month patient reported with complaints of abdominal discomfort and difficulty in breathing on exertion. No h/o fever or vomiting. On examination, epigastric fullness +. 10 x 6 cm smooth surfaced,firm non-tender mass occupying epigastrium,right and left hypochondrium. Left base breath sounds were absent.

Trans abdominal ultrasound – Pseudocyst of pancreas occupying body and tail with left pleural effusion and ascites

Cect abdomen - Pseudocyst of pancreas occupying body and tail with left pleural effusion and ascites. Wall thickness 4mm.

Conservatively managed. 6 weeks after- cyst size reduced to 4 x 3 cm.

Case 6 26 year male presented with Abdominal pain for 2 weeks-Acute

onset,Epigastrium to start with later became diffuse,Continuous,pricking pain,radiating to back,relieved by leaning forward and with medications.H/o non-bilious vomiting immediately after food intake + for the past one week.H/o constipation + x 3 days. H/o yellowish discolouration of sclera with passage of high coloured urine and clay coloured stools x 4 days +. No h/o fever /pruritus/abdominal distension/recent loss of weight/loss of appetite.H/o intermittent epigastric pain x 3 months. No comorbidities. Chronic Alcoholism x 3 yrs >360ml/day-last drink 8 days back

Not Anaemic,Deeply Icteric,No clubbing,No Generalised Lymphadenopathy,No Pedal Edema

Examination of Abdomen- Abdomen flat, Tenderness + Epigastrium,Right Hypochondrium,No guarding/rigidity,No obliteration of liver dullness,No mass/organomegaly,No free fluid,Murphys sign –ve.

Ultrasound Abdomen: Normal study UGI SCOPY: Pangastritis/Erosive Antral

Gastritis,Bulbar healed duodenal lesions.Submucosal lesion at D2 entry with luminal obstruction ?Pseudocyst causing duodenal obstruction.

SVS: Extrinsic compression at the level of D2,scope not passed beyond

CECT ABDOMEN: Possibility of stricture at the junction of 3rd and 4th part duodenum causing luminal obstruction

MRCP: ?Intramural Pseudocyst in the submucosal layer of Duodenum at the junction of D2,D3

Patient was managed conservatively and clinically improved.

Follow up serial radiological investigations showed gradual regression and disappearance after 12 weeks

Conclusion Due to progress in sensitivity and more widespread availability of diagnostic

imaging techniques, the incidence of pancreatic pseudocysts seems to be increasing steadily. .

In the above series the different presentations of pseudocyst of pancreas and the different techniques of management was elaborated

The majority of these cysts are asymptomatic, and the decision whether or not to operate is not always straightforward

The apparent question is how to proceed after the detection of an asymptomatic pancreatic cyst choosing one of the following options: no further investigations, additional imaging ± fine needle aspiration (FNA), surveillance, or surgical/endoscopic treatment.

Intervention is contemplated if the patient has Symptoms,if complications develop or a distinction has to be made between a pseudocyst and a tumour

References

Sabiston textbook of surgery,19th edition

Schwartz’s Principles of surgery,9th edition

Novel Technique in the Management of Obstructive Jaundice Caused by Pancreatic Pseudocyst , Archives of ClinicalExperimental Surgery,Gautham Krishnamurthy, Venkatesh Gottumukala, A Rajendran, P Darwin

www.giejournal.org ,GASTROINTESTINAL ENDOSCOPY Volume 77, No. 6 : 2013

World J Gastroenterol 2009 January 7; 15(1): 38-47 wjg@wjgnet.com World Journal of Gastroenterology ISSN 1007-9327

Pancreatic pseudocysts (Part I)Article by John Baillie, MB, ChB, FRCP,Durham, North Carolina