Pancreatitis Ag 3.Fluid Collections

8/13/2019 Pancreatitis Ag 3.Fluid Collections

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CLINICAL REVIEW

Fluid Collections in and Around thePancreas in Acute Pancreatitis

Alexander Brun, MD, Nana!ra" A#ar$al, MD, FRCP%C&, FACS,MP',$

and C(S( Pitchu"oni, MD, FRCP%C&, MACP, MAC)( MP'*

A+stract -he ad.ent o/ co"0uted to"o#ra0hic scan $ith its $ide usein the e.aluation o/ acute 0ancreatitis has o0ened u0 a ne$ to0ic in0ancreatolo#1 i(e( 2uid collections( Fluid collections in and aroundthe 0ancreas occur o/ten in acute 0ancreatitis and $ere de3ned +1the Atlanta S1"0osiu" on Acute Pancreatitis in 4556( -$o decadessince the Atlanta Con/erence additional ex0erience has+rou#ht to li#htthe inade7uac1 and 0oor understandin# o/ the ter"s used +1 differents0ecialists in.ol.ed in the care o/ 0atients $ith acute 0ancreatitis $heninter0retin# i"a#in# "odalities and the need /or a uni/or"l1 usedclassi3cation s1ste"( -he de3ciencies o/ the Atlanta de3nitions andad.ances in "edicine ha.e led to a 0ro0osed re.ision o/ the Atlantaclassi3cation 0ro"ul#ated +1 the Acute Pancreatitis Classi3cationWor!in# )rou0( -he ne$l1 used ter"s 8acute 0eri0ancreatic 2uidcollections,9 80ancreatic 0seudoc1st,9 80ostnecrotic0ancreatic:0eri0ancreatic 2uid collections,9 and 8$alled;off0ancreatic necrosis9 are to +e clearl1 understood in the inter0retation o/i"a#in# studies( -he current treat"ent "ethods /or 2uid collections aredi.erse and de0end on accurate inter0retations o/ radiolo#ic tests(Mana#e"ent o0tions include conser.ati.e treat"ent, 0ercutaneouscatheter draina#e, o0en and la0arosco0ic sur#er1, and endosco0icdraina#e( -he choice o/ treat"ent de0ends on a correct dia#nosis o/ thet10e o/ 2uid collection( In this stud1 $e ha.e atte"0ted to clari/1 the"ana#e"ent and clinical /eatures o/ different t10es o/ 2uid collections asthe1 ha.e +een initiall1 de3ned under the 4556 Atlanta Classi3cation

and re.ised +1 the Wor!in# )rou0 Clin )astroenterol 6?44@46&

ince the ad.ent o/ a+do"inal ultrasound %S& andco"0uted to"o#ra0h1 %C-& in the earl1 45?s, the

reco#nition o/ acute 2uid collections in acute 0ancreatitis %AP&has increased dra"aticall1 alon# $ith a clearer under; standin# o/

their natural histor1 and "ana#e"ent( -he ra0id rise in thedia#nosis o/ 2uid collections has lead to continuous chan#es in the

no"enclature and "ana#e"ent o/ di erentff

Fro" the De0art"ent o/ Medicine, Ro+ert Wood >ohnson School o/Medicine@ *Ne$ Gor! Medical Colle#e, Ro+ert Wood >ohnsonSchool o/ Medicine:Drexel ni.ersit1, 'e0atolo#1, Clinical Nutri; tion,Saint Peterohnson School o/

Medicine:Drexel ni.ersit1, 'e0atolo#1, Clinical Nutrition, SaintPeter Clin )astroenterol Volu"e , Nu"+er , Au#ust 6?44
mailto:[email protected]://www.jcge.com/http://www.jcge.com/mailto:[email protected]


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$$$(c#e(co"r 6?44 Li00incott Willia"s K Wil!ins

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-ABLE 4( Co"0arison o/ Classi/ication Sche"es o/ AP Atlanta Classi/ication .s( Wor!in# )rou0 Classi/ication

Acute0ancreatitisAtlanta Classi3cation %4556&4 Wor!in# )rou0 %6??&46

%4& Acute 0ancreatitis %4& Acute0ancreatitis%a& Mild %"ini"al or#an d1s/unction,

une.en reco.er1&%+& Se.ere %or#an /ailure and:or local

co"0lications&

%a&Non;se.ere %no or#an /ailure or or#an/ailurerHh in duration&

%+& Se.ere %or#an /ailureNHh in duration&

%c& Assess"ent o/ Se.erit1 %c& Assess"ent o/ Se.erit1Or#an Failure and S1ste"icCo"0licationsPro#nostic si#ns%i& Ranson


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> Clin )astroenterol Volu"e , Nu"+er , Au#ust 6?44 Fluid Collections in and Around

o/ 3+rous tissue(46,4 -hese collections can +e sterile orin/ected( nder the 4556 Atlanta Classi3cation ter"s suchas 80ancreatic 2uid collections,95 80eri0ancreatice usions,ff 94 and 8extra0ancreatic 2uid collections,94H ha.e all+een used to descri+e APFCs(

Incidence

APFCs occur in ?T to ?T o/ 0atients $ith APusuall1 $ithin H hours o/ AP onset( More than ?T o/ casesresol.e s0ontaneousl1 $ithin the 3rst se.eral $ee!s(4B,45,6?

Patho#enesis-he 0atho#enesis o/ APFCs "a1 +e /ro" a ru0ture o/ a

s"all +ranch o/ the 0ancreatic duct or /ro" ede"a due to0arench1"al and:or 0eri0ancreatic in2a""ation in thea+sence o/ necrosis, and ha.e no connection $ith the ductals1ste"( -he1 are usuall1 sterile, +ut occasionall1 "a1 +ehe"orrha#ic and:or +eco"e in/ected( -he exact co"0osi; tiono/ these collections is not !no$n(4 APFCs usuall1 start $ithand contain sterile 2uid rich in 0roteins( -he1 "a1 or "a1 notcontain hi#h concentrations o/ 0ancreatic en*1"es and ha.e a2uid co"0osition si"ilar to that o/ 0las"a(H -he si*e o/ the2uid collections .ar1(64 Lar#e 2uid collections are co""onl1locali*ed in the anterior 0ara; renal s0ace and lesser sac(APFCs ha.e a tendenc1 to +e "ore on the le/t side than on the

ri#ht side@ consistent $ith the /act that "ost o/ the 0ancreatic#land is located to the le/t o/ the s0ine( APFCs can tra.eldo$n to the 0el.is, in.ol.e the "esocolon, s"all +o$el"esenter1, enter the 0erineal ca.it1, and 0resent as ascites(Rarel1, 2uid "a1 collect in the 3ssures o/ the li#a"entu".enosu", the s0lenic hilu", the 0el.is, or e.en the"ediastinu"(44

i"a#in# studies, APFCs cannot +e dia#nosed +1 0h1sicalexa"ination( A contrast enhanced C- %CEC-& scan "a1sho$ 2uid collections $hich "a1 +e ill de3ned andhetero#eneous $ith attenuation .alues o/ 6? to ? '( -helatter re0resents a co"+ination o/ /at necrosis,extra.asated 0ancreatic en*1"es, in2a""ator1 exudates, andhe"orrha#e(6 In the "idst o/ 2uid collections the 0ancreatic#land "a1 re"ain nor"al, ede"atous, or contain .ar1in#

de#rees o/ necrosis( So"eti"es, it "a1 +e di cultffi todi erentiateff APFCs /ro" PNPFCs, es0eciall1 in the 3rst $ee!or 6( In such instances, a re0eat CEC- or "a#neticresonance i"a#in# %MRI& a/ter a $ee! $ill +e a+le todelineate the necrosis and distin#uish APFCs /ro" PNPFCs(

Mana#e"entAs APFCs re"ains sterile and are ex0ected to re#ress

s0ontaneousl1, care/ul and continued o+ser.ation alone isneeded in the lar#e "aorit1 o/ 0atients( In /act, "echanicalinter.ention "a1 cause the sterile 2uid to +eco"e in/ected and,there/ore, %C-;#uided& 0ercutaneous as0iration should +e

0er/or"ed to con3r" and treat onl1 $hen APFCs are clinicall1sus0ected o/ +ein# in/ected(H

PSEDOCGS-

De/inition-he current Atlanta criteria de3nition o/ 0seudoc1st is a

collection o/ 0ancreatic uice enclosed +1 a $all o/ 3+rous or#ranulation tissue, $hich arises as a result o/ AP, 0ancreatictrau"a, or chronic 0ancreatitis(4,4 Pseudoc1sts occur at least $ee!s a/ter the start o/ AP( -he1 contain clear, 0ancreatic

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Natural 'istor1 en*1"e;rich 2uid and are "ost o/ten sterile( Althou#h

It is di cultffi to 0redict the course o/ APFCs at theonset o/ AP( APFCs that do not resol.e can de.elo0 into a

0seudoc1st, either sterile or in/ected %ter"ed a+scess under the4556 Atlanta Classi3cation& %-a+le 4&( It is not clearl1understood $h1 the "aorit1 o/ APFCs re#ress $hile a /e$

0ersist to 0seudoc1st /or"ation( Baltha*ar66 3rst noted that 2uidcollection can correlate $ith se.erit1 and AP outco"e( In his C-#radin# o/ AP /ro" A to E %-a+le 6&, #rade D $as su##ested+1 si"0le 2uid collection and #rade E +1 6 or "ore collections(Co"+ined "or+idit1 and "ortalit1 in #rade D and E $as T

and 4T, res0ecti.el1( Maorit1 o/ the 2uid collections resol.eds0ontaneousl1(66 It is not a #ood0redictor o/ "or+idit1(

Dia#nosisI"a#in# studies indicate that APFCs are irre#ular in

sha0e, "a1 +e "ulti0le, lac! a $ell;de3ned $all, and ha.e anindistinct inter/ace +et$een the 2uid and adacent or#ans(6

-hese APFCs should+e di erentiateff d /ro" ascites(-he reco#nition o/ APFCs as a distinct entit1 /ro"

PNPFCs is essential in deter"inin# the need /or inter.en;tion, as o00osed to o+ser.ation alone( In the a+sence o/

-ABLE 6( Baltha*ar Criteria66

C- )radeA Nor"alB Pancreatic enlar#e"ent onl1C Peri0ancreatic in2a""ationD One 2uid collectionE More than 4 2uid collection

+e1ond the /ocus o/ this stud1, $e ha.e to+rie21 discuss the

ter" 8chronic 0seudoc1st,9 $hich has+een /re7uentl1 used inliterature to distin#uish the c1st /ro" an 8acute9 one( -heter" 8acute 0seudoc1st9 re/ers to a $ell;de3ned $alled;off2uid collection that0ersists $ee!s a/ter the onset o/ AP( Incontrast, a chronic 0seudoc1st is associated $ith chronic0ancreatitis and is not 0receded +1 a clear e0isode o/ AP(-hese ter"s are not currentl1 0o0ular and are not used in the

Wor!in# )rou0


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#land or +ecause o/ ductal disru0tion resultin# /ro"necrosis that accu"ulates in a s0ace adacent to the0ancreas( In a 0eriod o/ or "ore $ee!s the surroundin#in2a""ation causes the de.elo0"ent o/ a none0itheliali*ed $allco"0osed o/ #ranulation tissue and +lood .essels, $hichor#ani*es $ith "ore connecti.e tissue and 3+rosis( At 0resent,exce0t /or si#ni3cant 0ancreatic necrosis %U6BT&, no othersalient ris! /actors ha.e +een de3ned /or 0seudoc1sts( Nealon

et al ha.e classi3ed the ductal chan#es associated $ith0seudoc1sts in 0ancreatitis as /ollo$s t10e I, nor"al duct@t10e II, duct stricture@ t10e III, duct occlusion or8disconnected duct9@ and t10e IV, chronic 0ancreatitis(Further"ore, in each t10e a su+cate; #or1 o/ 8a9 re0resentsno co""unication +et$een the 0ancreatic duct and the

0seudoc1st and su+cate#or1 8+9 re0resents a co""unication(O/ the 0atients, 46 had s0ontaneous resolution $ith HTo/ the" +ein# t10e I( -he success o/ 0ercutaneous draina#e $asHT in t10e I, 5T in t10e II, and ?T in t10es III and IV(Ductal chan#es can 0redict resolution and #uide the t10e o/treat"ent #i.en(

Pseudoc1sts can +e locali*ed in the s0leen, the li.er, andrarel1 in the !idne1( Pseudoc1st in the s0leen is the "ost/re7uent s0lenic co"0lication in AP(, -he /or"a; tion o/0seudoc1st in the s0leen can result /ro" direct in.asion or/ro" the e ectff o/ 0ancreatic di#esti.e uice or the li7ue/acti.ede#eneration o/ s0lenic in/arction due to thro"+osis o/ s0lenic.essels(

Pseudoc1sts in the li.er are usuall1 in the le/t lo+e, and area rare occurrence( -he "echanis" o/ /or"ation is "ost li!el1+1 2uid in the lesser sac accu"ulatin# +et$een the lea.es o/the he0ato#astric li#a"ent into the s0ace +et$een the sto"achand the le/t lo+e o/ the li.er(4,H,5 Althou#h renal in.ol.e"entis rare, 0ancreatic 2uid can see0 throu#h )erota /ascia, the3+rous tissue that surrounds the !idne1, in $hich case it $ouldco""onl1 in.ol.e the le/t !idne1(?

Natural 'istor1A00roxi"atel1, ?T o/ 0seudoc1sts %ran#e, T to

HT& resol.e s0ontaneousl1(,4 Possi+l1 the ductaldisru0tion that leads to extra.asation o/ 0ancreaticen*1"es seals offs0ontaneousl1 resultin# in a+sor0tion o/2uid( Duct disru0tions can occur as a result o/ necrosis or$hen 0eri0ancreatic collection /ollo$s lea!a#e o/ 0ancrea;ticuice /ro" the in2a"ed area o/ the #land( S0ontaneous

resolution also occurs +1 draina#e into the 0ancreaticductal s1ste", ru0ture o/ the c1st ca0sule, or +1 s0onta;neous draina#e into an adacent hollo$ .iscus such as thecolon or sto"ach(

Studies +ased on S exa"inations sho$ed that0seudoc1sts 0resentin# /orS$ee!s had a ?T resolutionrate and 6?T co"0lication rate, $hereas those0resentin#/or "ore than 46 $ee!s usuall1 did not resol.e and had aT co"0lication rate( Nearl1 all 0seudoc1sts %5?T&Sc" in dia"eter resol.e s0ontaneousl1,,6, $hereasT o/ c1sts N4? c" $ill re7uire sur#ical draina#e(6,

'o$e.er, Soliani et alH o+ser.ed no di erencesff in"or+idit1, "ortalit1, or recurrence in 4 0atients $ith

0seudoc1sts N4? c" %includin# 45 N4A c"& $hen co";

0ared $ith ?0atients $ith 0seudoc1stsS4?c"( Si"ilarl1,other o+ser.ers ha.e /ound that the si*e and duration o/c1sts do not ha.e a si#ni3cant i"0act, su##estin# that thereare no strict si*e cut;offcriteria "andatin# inter.ention(5

-here/ore, the old conce0t %8rule o/ 9& that o+ser.ation o/c1stsNC c" and0ersistin# lon#er than $ee!s is /ruitlessand ha*ardous is no lon#er true( At the sa"e ti"e, there are

no 0ros0ecti.e indicators that relia+l1 0redict the 0ro#nosis o/ a0seudoc1st(

Dia#nosisClinical "ani/estations o/ 0seudoc1sts are related to local

"ass e ect(ff -he s1"0to"s include a+do"inal 0ain, earl1

satiet1, $ei#ht loss, and /e.er( Fe.er should raise sus0iciono/ 0seudoc1st in/ection( Wei#ht loss due to #astric or duodenalco"0ression is o+ser.ed in 6?T o/ 0atients(?

>aundice /ro" +ile duct co"0ression occurs in 4?T o/0atients, 0roducin# s1"0to"s o/ scleral icterus, dar! urine,acholic stools, and 0ruritis(?,4 Pleural e usion,ff es0eciall1 onthe le/t, "a1 +e a /eature( Ch1lous ascites and 0ortalh10ertension ha.e also +een re0orted in association $ith0seudoc1sts(6 Ph1sical exa"ination seldo" is dia#nosticexce0t $hen there is a 0al0a+le "ass $ith +i# c1sts that ares"ooth, 3r", o/ten nontender and "o.e $ith+reathin#(6,

Clinicall1 a 0seudoc1st is sus0ected $hen %4& an e0isode o/0ancreatitis /ails to resol.e@ %6& the a"1lase le.els are0ersistentl1 hi#h@ %& a 0atient has continuous a+do"inal 0aina/ter clinical resolution o/ AP@ or %& an e0i#astric "ass is/elt a/ter an e0isode o/ AP(6 'o$e.er, "ost0seudoc1stsare identi3ed +1 serial i"a#in# o/ APFCs(

A00roxi"atel1, 4?T o/ 0ancreatic c1sts are neo0lastic(-here/ore, there is a need to clearl1 esta+lish a dia#nosis o/

0seudoc1st and exclude a c1stic neo0las"( A+sence o/ ahistor1 or si#ns o/ acute:chronic 0ancreatitis and:or 0ancrea; tictrau"a should raise a hi#h index o/ sus0icion /or a c1sticneo0las"( On C- scan, a 0seudoc1st usuall1 a00ears as around or o.al, s1""etric, thin;$alled %4 to 6 ""& ca0sule"easurin# S4 ' %Fi#( 4&( Detection o/ une.en ca0sulethic!ness, se0tations, and in.ol.e"ent o/ 0eri0heral orlu"inal nodules are "ore consistent $ith a c1stic neo;0las"(, Fine;needle as0iration $ith C-:S:endosco0ic S%ES& #uidance o/ 0seudoc1st "a1 /acilitate dia#nosis( -heas0irated 2uid is to +e tested /or c1tolo#1, a"1lase le.el, andtu"or "ar!ers( A hi#h a"1lase concentration hel0s tocon3r" a ductal disru0tion leadin# to0seudoc1st /or"ation, +ut nosin#le test can de3niti.el1 rule out a c1stic neo0las"( Ele.atedc1st 2uid a"1lase concentrations "a1 also +e seen in side;+ranch intraductal 0a0illar1 "ucinous neo0las"s( -he 0resenceo/ "ucin and e0ithelial cells on c1tolo#1 %lo$ sensiti.it1&,"a!es c1stic neo0las" "ore li!el1(

FI)RE 4( Multi0le 0ancreatic 0seudoc1sts(


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A retros0ecti.e case;control stud1 di.ided 446 c1stic 0an;creatic lesions into "ucinous and non"ucinous lesions that $ereulti"atel1 sur#icall1 resected and co"0ared $ith their0reresection ES, c1tolo#1, and 2uid tu"or "ar!ers( Acarcinoe"+r1onic anti#en le.el o/ 456 n#:"L or #reater $as/ound to +e "ore accurate than "or0holo#1 o/ the c1st +1 ESor e.en c1tolo#1 in "a!in# a distinction+et$een the "ucinousand non"ucinous lesions( Durin# sur#er1 it is 0rudent to

ins0ect the interior o/ the 0seudoc1st /or e.idence o/ a tu"orand to 0er/or" a +io0s1 o/ the c1st $all i/ re7uired(Air +u++les in a 0seudoc1st indicate the 0resence o/

in/ection %rarel1 3stula&( When in/ection o/ the 0seudoc1st issus0ected due to /e.er, a )ra" stain should +e done o/ theas0irate( -he "ost co""on +acteria cultured /ro" the

0seudoc1st are enteric "icroor#anis"s, such as Escherichia coli,Bacteroides s0ecies, Entero+acter s0ecies, =le+siella s0ecies,and Stre0tococcus /aecalis(H 'o$e.er, in the a+sence o/ clinicalindication o/ in/ection, ES;#uided 3ne;needle as0iration "a1result in in/ected 0ancreatic 0seudoc1sts and is 0ro+a+l1unnecessar1 in0atients $ith a histor1 o/ se.ere AP(

-here are no de3niti.e la+orator1 tests /or dia#nosin#a 0ancreatic 0seudoc1st( A 0ersistentl1 ele.ated seru"a"1lase le.el "a1 +e 0resent in T o/ 0atients $ith

0seudoc1sts( Plain radio#ra0hs o/ the a+do"en are not use/uland onl1 occasionall1 sho$ dis0lace"ent o/ the #astric+u++leor calci3cation in the c1st $all( S e.aluation, +ecause o/ itscon.enience and lo$er cost, is used to "onitor chan#ein 0seudoc1st si*e(5 ltrasono#ra0h1 is inex0ensi.e, non;in.asi.e, and has a sensiti.it1 o/ T to 5?T /or detectin#

0seudoc1sts( At the sa"e ti"e, it is 0oor at .isuali*in# s"all0seudoc1sts, is o0erator de0endent, and is in2uenced+1 lar#e+od1 ha+itus, o.erl1in# +o$el #as, and uncoo0erati.e0atients( -hese /actors are eli"inated $hen ES is used(ES is a+le to detect "ost c1stic lesions and $as sho$n to +esu0erior to "ultidetector C- in lesionsS6c" in dia"eter(?

'o$e.er, ES re7uires conscious sedation and, si"ilar to thetransa+do"inal S, is o0erator de0endent(

Currentl1, CEC- is the "ost accurate test /or sho$in#a 0seudoc1st $ith a sensiti.it1 o/ 5?T to 4??T and is thedia#nostic stud1 o/ choice(4,6 A CEC- also ena+leslocali*ation o/ the 0seudoc1st in relation to surroundin#or#ans and .ascular structures in 0re0aration /or 0ossi+ledraina#e( Oral contrast o0aci3es enteric structures ada;cent to the 0ancreas, $hich allo$s di erentiationff o/ 2uid;3lled +o$el /ro" 0ancreatic 2uid collections(H Des0iteCEC-


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Endosco01Endosco0ic draina#e can +e 0er/or"ed throu#h a

trans0a0illar1 a00roach, a trans"ural a00roach, or +oth( -hetreat"ent o/ choice is usuall1 dictated +1 the treatin#

0h1sician


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+1 lar#e;si*e catheters and 0re"ature re"o.al o/ catheters+e/ore cessation o/ draina#e $ill result in recurrence( 'o$e.er,in sta+le 0atients internal draina#e o/ an in/ected0seudoc1st +1sur#ical or endosco0ic 0rocedures has +een sho$n to +e sa/eand e ecti.ff e and can, there/ore, +e0er/or"ed as the initialtreat"ent(4? -he 0ro#nosis /or an in/ected 0ancreatic 0seudoc1stis extre"el1 #ood(?

A 0seudoc1st can ru0ture into the 0eritoneal ca.it1,0leural s0ace, or into the .ascular s1ste"4?,4? and, on rareoccasions, ru0ture into the 0ortal .ein or the urinar1 tracthas +een re0orted(4?,4? It can 0resent as a silent e.ent

0roducin# 0ancreatic ascites, 0leural e usion,ff or an acutea+do"inal e.ent(4?H,4?5 Ru0ture into the #astrointestinaltract can +e associated $ith .o"itin#, diarrhea, "elena,he"ate"esis, or "assi.e lo$er #astrointestinal +leedin#(44?

Ru0ture into the0eritoneal ca.it1 can lead to0eritonitis orhe"orrha#ic shoc! $ith "ortalit1 as hi#h a ?T(444

E"er#ent sur#ical ex0loration $ith external draina#e anda+do"inal la.a#e is usuall1 the "ethod o/ treat"ent as the$all o/ the ru0tured c1st is too $ea! to hold sutures and the0atient is he"od1na"icall1 unsta+le(

B1 erodin# into an adacent .essel, a 0seudoc1st can/or" a 0seudoaneur1s" and he"orrha#e( Massi.e he"or;rha#e, $hich can occur in a00roxi"atel1 T to 4?T o/0atients $ith 0seudoc1sts, is the "ost /eared co"0lica;tion(44644 Most co""onl1, there is "assi.e+leedin# intothe #astrointestinal tract, /ollo$ed+1 intra;a+do"inal +leed;in# and, in rare cases there "a1 +e +leedin# into the0ancreatic duct %he"osuccus 0ancreaticus&( Erosions "ostco""onl1 occur into the s0lenic, #astroduodenal, and

0ancreaticoduodenal arteries, and less /re7uentl1 into the#astric, "iddle colic, or the he0atic arter1(4444 Pseudoa;neur1s"s can occur $ithin the 0seudoc1st itsel/ or on its

0eri0her1( Pseudoaneur1s" should+e sus0ected in the e.ento/ re0eated e0isodes o/ #astrointestinal +leedin#, 0resence o/an enlar#in# 0ulsatile a+do"inal "ass, or an a+do"inal+ruitand in 0atients $ith increasin# a+do"inal 0ain or anunex0lained dro0 in he"atocrit( Bolus d1na"ic C- scan isthe "ost use/ul initial dia#nostic test( It detects the 0resence o/he"orrha#e %attenuation N?'& and 0seudoaneur1s"sand should +e 0er/or"ed +e/ore an1 draina#e 0rocedure(Inter.entional radiolo#1 is then the0rocedure o/ choice usedto locate and 0er/or" e"+oli*ation o/ the +leedin#source(44,44 Distal 0ancreatecto"1 "a1 +e indicated i/+leedin# arises /ro" the +od1 or tail o/ the 0ancreas(44H

Needle as0iration o/ all 0ancreatic0seudoc1sts should +edone in the o0eratin# roo" +e/ore o0enin# the"(

Althou#h 0ancreatic ascites can occur earl1 in AP, it isusuall1 secondar1 to lea!a#e /ro" a 0seudoc1st %?T& or0ancreatic duct %4?T to 6?T& and occurs "ore o/ten in0atients $ith chronic 0ancreatitis(445464 Pancreatic ascitesis not o ciall1ffi de3ned in the 4556 Atlanta Classi3cation()enerall1, 0ancreatic ascites is a 0er"anent disru0tion o/the "ain 0ancreatic duct( -he esta+lish"ent o/ a co""u;nication +et$een the0ancreas and 0eritoneal ca.it1 induces"assi.e chronic ascites( Clinicall1, 0ancreatic ascites 0re;sents $ith increasin# a+do"inal #irth, distention, 0ain,$ei#ht loss, and nausea(44546 In the "aorit1 o/ cases theascites is su+stantial as the 0ancreas0roduces o.er 4 L o/exocrine secretion 0er da1(46 A 0rotein count o/ NI #:dLand an a"1lase le.el N4??? units on0eritoneal as0irationcon3r"s the dia#nosis(445 ERCP is the0rocedure o/ choiceused to sho$ the site o/ lea!a#e(46 -reat"ent usuall1 startsconser.ati.el1 $ith thera0eutic 0aracentesis, naso#astricsuction, restriction o/ oral inta!e, and use o/ a so"atostatin

analo#( -his is success/ul in NB?T o/ 0atients(46 I/ theconser.ati.e a00roach /ails, treat"ent $ith endosco0ic stent

0lace"ent should +e considered and sur#ical thera01 is reser.ed/or those $ho /ail(46,46 Sur#ical 0rocedures are directed +1the t10e o/ ductal disru0tion /ound on ERCP(466,46Re0orted o0erati.e "ortalit1 is 6?T and the recurrence rateis 4BT(466,46

Mild, transitor1 aundice can +e seen in AP due toin2a""ation o/ the duodenal $all and a"0ulla o/ Vater orin2a""ator1 narro$in# o/ the intra0ancreatic se#"ent o/the co""on+ile duct( 'o$e.er, $hen aundice 0ersists orde.elo0s a/ter a /e$ $ee!s, a co"0ression o/ the co""on+ile duct +1 a lar#e c1st is "ost li!el1( Endosco01 $ith+iliar1 stentin# until resolution or treat"ent o/ the0seudoc1st is the thera01 o/ choice /or co"0ression o/ theco""on +ile duct(H

Portal h10ertension can +e the result o/ 0seudoc1stco"0ression or occlusion o/ the 0ortal .ein and s0lenic .einthro"+osis( S0lenic .ein thro"+osis $ith #astric .ariceal/or"ation is re/erred to as le/t sided or sinistral 0ortalh10ertension( S0lenecto"1 $ith excision or draina#e o/

0seudoc1st is indicated /or+leedin# /ro" #astroeso0ha#eal.arices(

PANCREA-IC NECROSIS

De/inition-he current de3nition o/ 0ancreatic necrosis is a"+i#;

uous( Pancreatic necrosis under the Atlanta Classi3cation isde3ned as 8a di usff e or /ocal area%s& o/ non.ia+le 0ancreatic0arench1"a, t10icall1 associated $ith 0eri0ancreatic /atnecrosis(94 -he de3nition includes +oth sterile and in/ectednecrosis and does not di erentiatff e +et$een 0arench1"alnecrosis and 0eri0ancreatic /at necrosis(4 Better understandin# o/the 0atho0h1siolo#1 o/ necroti*in# 0ancreatitis, i"0ro.eddia#nostic "odalities, and ne$er ar"a"entariu" /or "ana; #in#co"0lications ha.e "ade it necessar1 to re.ise, u0date, andextend the Atlanta Classi3cation( -he Acute Pancreatitis

Classi3cation Wor!in# )rou0 has0ro0osed ane$

classi3ca; tion+ased on "or0holo#ic CEC- criteria that descri+e6 distinct t10es o/ AP %4& acute interstitial ede"atous0ancreatitis and %6& acute necroti*in# 0ancreatitis(46 Acutenecroti*in# 0ancreatitis is /urther su+di.ided into /or"s

0ancreatic 0arench1"al and associated 0eri0ancreatic necro; sis%"ost co""on&, 0ancreatic 0arench1"al necrosis alone %rare&,and 0eri0ancreatic necrosis alone %a00roxi"atel1 6?T o/0atients&(46 All t10es can +e sterile or in/ected( -here/ore,clinicall1 it is essential to deter"ine the0resence o/ necrosis, thesite o/ necrosis, and the0resence o/ in/ection(

IncidenceAP can +e clinicall1 "ild or se.ere, $here the

distin#uishin# /actor a"on# the 6 accordin# to the Wor!in#)rou0 is the 0ersistence o/ or#an /ailure +e1ond H hours in thelatter cate#or1( -he incidence o/ or#an /ailure is directl1associated $ith the extent o/ necrosis( Or#an /ailure occurs inT o/ 0atients $ith NB?T necrotic tissue, 6T o/ 0atients

$ith ?T to ?T, and in HT $hen the extent o/ necrosis isSI?T(46Mortalit1 o/ sterile and in/ected 0ancreatic necrosisis 4?T to 4T and ?T to T, res0ecti.el1(46,46H

PNPFCsNecroti*in# 0ancreatitis can +e associated $ith 2uid

collections( -hese are ter"ed PNPFCs and are not to +econ/used $ith acute 0ancreatic 2uid collections and


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FI)RE 6( Acute 0ostnecrotic 0eri0ancreatic /luid collection(

0seudoc1sts( PNPFCs contain +oth 2uid and necrotic tissue %Fi#(6&( O.er the course o/ $ee!s the necrosis e.ol.es into a necrotic2uid collection $ith +oth li7uid and solid de+ris( Sterile0ancreatic necrosis +e#ins to under#o li7ue/action $ithin the3rst 6 to da1s( -here is a continuu" /ro" initial solid necrosisto li7ue/action necrosis( Multi0le studies loo!in# at thecontents o/ necrotic tissue a/ter o0erati.e necrosecto"1sho$ed di erenff t le.els o/ li7ue/action o/ necrotictissue(,465,4? Maor 0ancreatic ductal da"a#e /re7uentl1, +utnot in.aria+l1, occurs in necroti*in# 0ancrea; titis(444 -hus,connection $ith the 0ancreatic ductal s1ste" "a1 or "a1 not +e0resent(

In the 3rst $ee!, it "a1 +e di cultffi to distin#uishAPFCs /ro" PNPFCs( On CEC- nor"al 0ancreatic tissue"easures H? to 5? ', $hereas 0ancreatic necrosis"easures S?'( A readin# o/ ? to H? ' stron#l1su##ests necrosis(H Solid de+ris "a1 +e nondiscerni+le on C-in necrotic 2uid collections due to its ho"o#enous a00earanceand can lead to incorrect dia#nosis o/ APFCs( Su+se7uentCEC- a/ter the 3rst or second $ee! "a1 +e necessar1(Di erentiationff o/ WOPN /ro" APFCs and0seudoc1sts isalso assisted +1 MRI and ES(

In/ected PNPFCs "a1 +e clinicall1 di cultffi todistin#uish /ro" sterile PNPFCs( When in/ected0ancreaticnecrosis is sus0ected, 0ercutaneous 3ne needle as0iration"a1+e indicated to con3r" the dia#nosis( As in the case o/

0seudoc1sts and APFCs, as0iration or draina#e o/ sterilePNPFCs is not ad.isa+le +ecause an atte"0t to drain "a1con.ert sterile PNPFCs into in/ected ones(4

WOPN

Si"ilar to the0atho#enesis o/ a 0seudoc1st, or#ani*a; tiono/ the PNPFCs o.er ti"e +1 a thic!ened $all o/ 3+rosis or#ranulation tissue $ithout an e0ithelial linin# at the inter/ace o/necrotic and .ia+le tissue results in the /or"ation o/ a $alled;offnecrosis %WOPN&( WOPN can +e sterile %Fi#( & or in/ected%Fi#( & and "a1 or "a1 not ha.e a co""unication $ith the

0ancreatic ductal s1ste"( Other ter"s 0re.iousl1 used todescri+e this entit1 ha.e +een 8or#ani*ed 0ancreaticnecrosis,9 8su+acute 0ancreatic necrosis,94 8necro"a,94

and 80seudoc1st associated $ith necrosis(94 It needs to +ee"0hasi*ed that CEC- is unrelia+le /or dia#nosin# WOPNdue to its ina+ilit1 to accuratel1 distin#uish +et$een0eri0ancreatic /at necrosis and0eri0ancreatic 2uid collection(4HMRI or ES "a1+e co"0le"entar1 aduncts(

FI)RE ( Walled;o// 0ancreatic necrosis sterile(

O.er the last 6? 1ears +ecause o/ i"0ro.ed dia#nostic andinitial "edical "ana#e"ent, a ne$ clinical strate#1 has e.ol.edin the "ana#e"ent o/ 0ancreatic necrosis that also a00lies toin/ected PNPFCs or in/ected WOPN( First, thera0euticinter.ention is indicated onl1 /or 0ro.en in/ected necrosis,other$ise conser.ati.e treat"ent should +e 0er; /or"ed(45,4?Second, the o0ti"al ti"in# /or inter.ention is a/ter the third or/ourth $ee! to allo$ de"arcation o/ 0ancreatic and0eri0ancreatic necrosis(45 Mortalit1 is si#; ni3cantl1 hi#her in0atients $ho are o0erated on +e/ore 6H da1s %6?(T .s( (4T,PR?(??6&(44 -hird, $hen S$ee!s since the initial e0isodehas ela0sed, 0ercutaneous draina#e usin# lar#e;+ore catheters canser.e as a +rid#e to de3niti.e sur#er1 or e.en success/uloutco"e( Fourth, recent studies ha.e sho$n that "ini"all1in.asi.e a00roaches, such as la0arosco0ic,46 0ercutaneousretro0eritoneal,4 and endo; sco0ic routes are as e7uall1

e ecti.ff e as o0en sur#ical de+ride"ent(4

Lastl1, deter"inationo/ the 0resence o/ a ductal co""unication is o/ 0otentiali"0ortance as it "a1 #uide thera01( -hese chan#es ha.econtri+uted to a su+stantial reduction o/ "ortalit1 to as lo$ asBT(4B

FI)RE ( Walled;o// 0ancreatic necrosis, in/ected, #as +u++lesin the necrotic area(


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-ABLE ( Indications /or Pancreatic Necrosecto"14A4

A( Positi.e 3ne needle as0irationB( Ne#ati.e 3ne needle as0iration in the settin# o/

Persistent s1"0to"s des0ite conser.ati.e thera01Se0sis s1ndro"e

C( )as on C- scanC- indicates co"0uted to"o#ra0h1(

Nealon et al 0ro0ose that 0ancreatic ductal chan#es,rather than co""unication +et$een the 0ancreatic duct,in2uence outco"e( In their stud1 o/ 4 0atients $ith se.erenecroti*in# 0ancreatitis, 0ercutaneous drainin# $as initiall1

0er/or"ed in 0atients, +ut /ailed in 4 %T&( Failure $as6T in t10e I, 6T in t10e II, and 4??T in t10e III%statisticall1 si#ni3cant $hen co"0ared $ith t10e I&(O0erati.e de+ride"ent $as 0er/or"ed in ?T o/ 0atients(Althou#h onl1 5T o/ t10e I 0atients had o0erati.ede+ride"ent, a si#ni3cantl1 lar#er nu"+er o/ t10e II and t10eIII 0atients %HT and HT, res0ecti.el1& re7uiredde+ride"ent(

-he o+ser.ation o/ Nealon et al that co""unication+et$een the 0ancreatic duct and 0seudoc1st did not in2uenceoutco"e can +e ex0lained+1 the /act that i"a#in# techni7ues arenot accurate in sho$in# the co""unication( Radio;#ra0hicall1 de"onstra+le co""unication $as e.ident in T o/those $ith t10e III %disconnected& duct( In contrast, d1e inectedinto the 0ercutaneous drain or directl1 into the 0seudoc1stdurin# o0eration sho$ed a co""unication +et$een the

0suedoc1st and the distal, isolated 0ancreatic duct in 5 o/ the5 t10e III 0atients %5T&(

Althou#h dia#nosis o/ in/ection is an a+soluteindicator /or thera0eutic inter.ention, deter"ination o/in/ected necrosis is di cultffi and challen#in#( In their serieso/ 4 0atients $ith necroti*in# 0ancreatitis, Rodri#ue*et al44 0ro.ed in/ection in onl1 4T o/ 0atients, 3ndin#that 3ne needle as0iration had 1ielded a /alse ne#ati.e in u0to 6T o/0atients, and C- indicated the0resence o/ #as inonl1 4T o/0atients( -he second "ost co""on indication

%6T& $as 80ersistent un$ellness(9 -hese 0atients had no0roo/ o/ in/ected necrosis,+ut re"ained s1"0to"atic %0ain,nausea, .o"itin#, 0ersistent lo$;#rade /e.er or ina+ilit1to tolerate oral /eedin#& des0ite 0rolon#ed conser.ati.ethera01( -he third "ost co""on reason /or sur#er1 $asse0sis s1ndro"e %4T& characteri*ed +1 deterioratin#clinical status and 0ersistent or $orsenin# or#an /ailure,usuall1 $ith leu!oc1stosis and /e.er, +ut ne#ati.e cultures%-a+le &( Posto0erati.e co"0lications o/ 0ancreaticnecrosecto"1 included he"orrha#e %(T&, endocrineinsu cienc1ffi %4T&, exocrine insu cienc1ffi %6?T&, and0ancreatic 3stula %4T&( Ninet1;/our 0ercent o/ 0ancreatic3stulas closed s0ontaneousl1(44

CONCLSIONS4( -he 4556 Atlanta S1"0osiu" on the Classi3cation o/ AP

$as a +rea!throu#h in de3nin# 2uid collections in andaround the 0ancreas(

6( -he de3nitions 0ro.ided in the Atlanta Classi3cation ha.e+een used inconsistentl1 and so"e ter"s ha.e not +een $ellacce0ted( Standardi*ed de3nitions and the correct usethereo/ are i"0ortant /or i"0ro.in# 0atient care, ade7uateco""unication +et$een treatin# 0h1sicians, andco"0arin# interinstitutional data /or

clinical research( Reco#ni*in# this de3cienc1, the AcutePancreatitis Classi3cation Wor!in# )rou0 has

0ro0osed a re.ision to the Atlanta Classi3cation(

( -he "aor su+sets o/ 2uid collections in AP as"odi3ed +1 the Wor!in# )rou0r( Dia#nosis and"ana#e"ent o/0ancreatic 0seudoc1sts $hat is the e.idence> A" Coll Sur#( 6??5@6?5H5(


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H( Strin#/ello$ ), Vansonnen+er# E, Casola ), et al( Mana#e;"ent o/ Fluid Collections in Acute Pancreatitis( -he PancreasAn Inte#rated -ext+oo! o/ Basic Science, Medicine andSur#er1( 6nd ed( Malden, MA Blac!$ell Pu+lishin# Li"ited@6??5(

5( Werner >, Feuer+ach S, hl W, et al( Mana#e"ent o/ acute0ancreatitis /ro" sur#er1 to inter.entional intensi.e care(

)ut( 6??@6(4?( Baron -'( -reat"ent o/ 0ancreatic0seudoc1sts, 0ancreaticnecrosis, and 0ancreatic duct lea!s( )astrointest Endosc ClinN A"( 6??@455, .ii(

44( Baltha*ar E>, Freen1 PC, .anSonnen+er# E( I"a#in# andinter.ention in acute0ancreatitis( Radiolo#1( 455@4565?(

46( Acute Pancreatitis Classi3cation Wor!in# )rou0( Re.isiono/ the Atlanta classi3cation o/ acute 0ancreatitis 6??H@

$$$(0ancreasclu+(co":resources:AtlantaClassi3cation(0d/(4( Mor#an DE( I"a#in# o/ acute0ancreatitis and its co"0lica;

tions( Clin )astroenterol 'e0atol( 6??H@4?4?H(4( Bradle1 EL III( A clinicall1 +ased classi3cation s1ste" /or

acute0ancreatitis( Su""ar1 o/ the International S1"0osiu"on Acute Pancreatitis, Atlanta, )a, Se0te"+er 44 throu#h 4,4556( Arch Sur#( 455@46HH5?(

4( Sie#el"an SS, Co0eland BE, Sa+a )P, et al( C- o/ 2uidcollections associated $ith 0ancreatitis( A>R A" > Roent;#enol( 45H?@44464446(

4( -ra.erso LW, =o*are! RA( Inter.entional "ana#e"ent o/0eri0ancreatic 2uid collections( Sur# Clin North A"( 4555@5, .iii;ix(

4( Ferrucci >- III, Mueller PR( Inter.entional a00roach to0ancreatic 2uid collections( Radiol Clin North A"( 6??@4464466, .ii(

4H( Ar.anita!is M, Delha1e M, De Maertelaere V, et al(Co"0uted to"o#ra0h1 and "a#netic resonance i"a#in# inthe assess"ent o/ acute 0ancreatitis( )astroenterolo#1( 6??@4646(

45( Bradle1 EL, )on*ale* AC, Cle"ents >L >r( Acute0ancreatic0seudoc1sts incidence and i"0lications( Ann Sur#( 45@4H(

6?( >ohnson CD( -i"in# o/ inter.ention in acute 0ancreatitis(Post#rad Med >( 455@5?54(

64( Ranson >', Ri/!ind =M, Roses DF, et al( Pro#nostic si#nsand the role o/ o0erati.e "ana#e"ent in acute 0ancreatitis(Sur# )1necol O+stet( 45@455H4(

66( Ranson >', Baltha*ar E, Cacca.ale R, et al( Co"0utedto"o#ra0h1 and the 0rediction o/ 0ancreatic a+scess inacute0ancreatitis( Ann Sur#( 45H@6?4(

6( Baltha*ar E>, =rins!1 ), Role o/ I"a#in# Methods in AcutePancreatitis Dia#nosis, Sta#in#, and Detection o/ Co"0lica;tions( Clinical Pancreatolo#1 For Practisin# )astroenterolo;#ists and Sur#eons( Ox/ord, = Blac!$ell Pu+lishin# Ltd@6??H?(

6( Marin#hini A, o"o ), Patti R, et al( Pseudoc1sts in acutenonalcoholic0ancreatitis incidence and natural histor1( Di#Dis Sci( 4555@454(

6( London N>, Neo0tole"os >P, La.elle >, et al( Serialco"0uted to"o#ra0h1 scannin# in acute 0ancreatitisa 0ros0ecti.e stud1( )ut( 45H5@?5?(

6( Dohert1 )M, La$rence WW( Pancreas( Current Dia#nosisand -reat"ent Sur#er1( 4th ed( SA Mc)ra$;'ill Co";0anies@ 6?4?65(

6( Laxson LC, Fro"!es >>, Coo0er"an M( Endosco0ic retro;#rade cholan#io0ancreato#ra0h1 in the "ana#e"ento/ 0ancreatic 0seudoc1sts( A" > Sur#( 45H@4?HH(

6H( =olars >C, Allen MO, Ansel ', et al( Pancreatic 0seudoc1stsclinical and endosco0ic ex0erience( A" > )astroenterol(45H5@H656(

65( Walt A>, Bou$"an DL, Wea.er DW, et al( -he i"0act o/technolo#1 on the "ana#e"ent o/ 0ancreatic 0seudoc1st(Fi/th annual Sa"uel >ason Mixter Lecture( Arch Sur#(455?@465(

?( I"rie CW, Buist L>, Shearer M)( I"0ortance o/ cause in theoutco"e o/ 0ancreatic 0seudoc1sts( A" > Sur#( 45HH@44546(

4( A""ann RW, A!o.+iant* A, Lar#iader F, et al( Course andoutco"e o/ chronic 0ancreatitis( Lon#itudinal stud1 o/a "ixed "edical;sur#ical series o/ 60atients( )astroentero;

lo#1( 45H@HH6?H6H(6( =ourtesis ), Wilson SE, Willia"s RA( -he clinical si#ni3;cance o/ 2uid collections in acute 0ancreatitis( A" Sur#(455?@555(

( Neo0tole"os >P, London N>, Carr;Loc!e DL( Assess"ent o/"ain 0ancreatic duct inte#rit1 +1 endosco0ic retro#rade0ancreato#ra0h1 in 0atients $ith acute 0ancreatitis( Br >Sur#( 455@H?555(

( Nealon W', Bhutani M, Riall -S, et al( A uni/1in# conce0t0ancreatic ductal anato"1 +oth0redicts and deter"ines the"aor co"0lications resultin# /ro" 0ancreatitis( > A" CollSur#( 6??5@6?H5?55@ discussion 55;H?4(

( Lan!isch P)( -he s0leen in in2a""ator1 0ancreatic disease()astroenterolo#1( 455?@5H?54(

( Fish"an E=, So1er P, Bliss DF, et al( S0lenic in.ol.e"ent in0ancreatitis s0ectru" o/ C- 3ndin#s( A>R A" > Roent#enol(

455@44(( 'astin#s OM, >ain =M, =hade"i M, et al( Intras0lenic

0ancreatic 0seudoc1st co"0licatin# se.ere acute 0ancreatitis(A" > )astroenterol( 45H@54H64H(

H( O!uda =, Su#ita S, -su!ada E, et al( Pancreatic0seudoc1stin the le/t he0atic lo+e a re0ort o/ t$o cases( 'e0atolo#1(4554@45(

5( Mo/red A, Cadranel >F, Dautreaux M, et al( Pancreatic0seudoc1st located in the li.er a case re0ort and literaturere.ie$( > Clin )astroenterol( 6???@?H4H(

?( Lilien/eld RM, Lande A( Pancreatic 0seudoc1sts 0resentin# asthic!;$alled renal and 0erine0hric c1sts( > rol( 45@444646(

4( Aranha )V, Prin* RA, Es#uerra AC, et al( -he nature andcourse o/ c1stic 0ancreatic lesions dia#nosed +1 ultrasound(

Arch Sur#( 45H@44HHHH(6( Bee+e DS, Bu+ric! MP, Onstad )R, et al( Mana#e"ent o/0ancreatic 0seudoc1sts( Sur# )1necol O+stet( 45H@456(

( Bradle1 EL, Cle"ents >L >r, )on*ale* AC( -he naturalhistor1 o/ 0ancreatic 0seudoc1sts a uni3ed conce0t o/"ana#e"ent( A" > Sur#( 455@4444(

( Geo C>, Bastidas >A, L1nch;N1han A, et al( -he naturalhistor1 o/ 0ancreatic0seudoc1sts docu"ented +1 co"0utedto"o#ra0h1( Sur# )1necol O+stet( 455?@4?444(

( Lau S-, Si"chu! E>, =o*are! RA, et al( A0ancreatic ductallea! should +e sou#ht to direct treat"ent in 0atients $ithacute0ancreatitis( A" > Sur#( 6??4@4H4444(

( Baltha*ar E>( Co"0lications o/ acute0ancreatitis clinical andC- e.aluation( Radiol Clin North A"( 6??6@?4644466(

( )ou1on B, Le.1 P, Rus*nie$s!i P, et al( Predicti.e /actors in

the outco"e o/ 0seudoc1sts co"0licatin# alcoholic chronic0ancreatitis( )ut( 455@4H64H6(

H( Soliani P, Uie#ler S, Fran*ini C, et al( -he si*e o/ 0ancreatic0seudoc1st does not in2uence the outco"e o/ in.asi.etreat"ents( Di# Li.er Dis( 6??@44?(

5( N#u1en BL, -ho"0son >S, Edne1 >A, et al( In2uence o/ theetiolo#1 o/ 0ancreatitis on the natural histor1 o/ 0ancreatic0seudoc1sts( A" > Sur#( 4554@466?@ discussion 4(

?( Bru##e WR( A00roaches to the draina#e o/ 0ancreatic0seudoc1sts( Curr O0in )astroenterol( 6??@6?HH56(

4( Mehta AI, McDo$ell DE( Pancreatic0seudoc1st as a causeo/ aundice( South Med >( 45H@44?64?, 44?(

6( McCor"ic! PA, ChronosN, Burrou#hs A=, et al( Pancreatic0seudoc1st causin# 0ortal .ein thro"+osis and 0ancreatico;0leural 3stula( )ut( 455?@44(

( )u"aste VV, Pitchu"oni CS( Pancreatic 0seudoc1st( )astro;enterolo#ist( 455@(( Allen P>, >a7ues DP, D


11/12

"ana#e"ent in 6?5 0atients( > )astrointest Sur#( 6??@5?5(

( Curr1 CA, En# >, 'orton =M, et al( C- o/ 0ri"ar1 c1stic0ancreatic neo0las"s can C- +e used /or 0atient tria#e andtreat"ent A>R A" > Roent#enol( 6???@4554?(

( )on*ale* O+eso E, Mur0h1 E, Bru##e W, et al( Pseudoc1st o/the0ancreas the role o/ c1tolo#1 and s0ecial stains /or "ucin(Cancer C1to0athol( 6??5@444?44?(

( Bru##e WR, Le$andro$s!i =, Lee;Le$andro$s!i E, et al(Dia#nosis o/ 0ancreatic c1stic neo0las"s a re0ort o/ thecoo0erati.e 0ancreatic c1st stud1( )astroenterolo#1( 6??@464?4(

H( Cantasde"ir M, =ara B, =antarci F, et al( Percutaneousdraina#e /or treat"ent o/ in/ected 0ancreatic0seudoc1sts(South Med >( 6??@544?(

5( -hoeni RF, Blan!en+er# F( Pancreatic i"a#in#( Co"0utedto"o#ra0h1 and "a#netic resonance i"a#in#( Radiol ClinNorth A"( 455@44?H444(

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4( -a!eshita =, Furui S, -a!ada =( Multidetector ro$ helical

C- o/ the0ancreas .alue o/ three;di"ensional i"a#es, t$o;di"ensional re/or"ations, and contrast;enhanced "ulti0hasici"a#in#( > 'e0ato+iliar1 Pancreat Sur#( 6??6@5H6(

6( =i" 'C, Gan# DM, >in W, et al( Multi0lanar re/or"ationsand "ini"u" intensit1 0roections usin# "ulti;detector ro$C- /or assessin# ano"alies and disorders o/ the 0ancreatico;+iliar1 tree( World > )astroenterol( 6??@444H(

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co"0ared $ith C- and S( Radiolo#1( 455@6?H(( Var#hese >C, Masterson A, Lee M>( Value o/ MR 0ancrea;

to#ra0h1 in the e.aluation o/ 0atients $ith chronic 0ancrea;titis( Clin Radiol( 6??6@5?4(

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H( Natural ori3ce translu"enal endosco0ic sur#er1 %NO-ES&c1st#astrosto"1 /or the treat"ent o/ 0ancreatic0seudoc1sts%NC-??45&( 6??@ Clinical -rial( A.aila+le at htt0::$$$(clinicaltrials(#o.( Accessed Dece"+er H, 6?4?(

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co"0ared $ith internal draina#e in the "ana#e"ent o/0ancreatic0seudoc1st( Ann Sur#( 4556@644@ discus;sion H(

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sco01( 6??@55H(H( Wec!"an L, =1lan0aa ML, Puola!!ainen P, et al( Endo;sco0ic treat"ent o/ 0ancreatic 0seudoc1sts( Sur# Endosc(6??@6???(

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H?( De.iere >, Bueso ', Bai*e M, et al( Co"0lete disru0tion o/the "ain 0ancreatic duct endosco0ic "ana#e"ent( )astro;intest Endosc( 455@64(

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H6( A*ar RR, Oh GS, >anec EM, et al( Wire;#uided 0ancreatic0seudoc1st draina#e +1 usin# a "odi3ed needle !ni/e andthera0eutic echoendosco0e( )astrointest Endosc( 6??@HH56(

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"ana#e"ent o/ 0ancreatic0seudoc1sts( Br > Sur#( 455@H4H4(

H( =o*are! RA( Pancreatic stents can induce ductal chan#esconsistent $ith chronic 0ancreatitis( )astrointest Endosc(455?@55(

HH( S"its ME, Rau$s EA, -1t#at )N, et al( -he e cac1ffi o/endosco0ic treat"ent o/ 0ancreatic 0seudoc1sts( )astrointestEndosc( 455@66?66?(

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54( Shar"a SS, Bhar#a$a N, )o.il A( Endosco0ic "ana#e"ento/ 0ancreatic0seudoc1st a lon#;ter" /ollo$;u0( Endosco01(6??6@6?6?(

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5( Ste0han RN, Bradle1 EL III( Pancreatic in/ections( )astro;

enterolo#ist( 455@44H(5( Isai S, -a!ada -, =a$arada G, et al( >PN )uidelines /or the

"ana#e"ent o/ acute 0ancreatitis sur#ical "ana#e"ent(> 'e0ato+iliar1 Pancreat Sur#( 6??@4H(
http://www.clinicaltrials.gov/http://www.clinicaltrials.gov/http://www.clinicaltrials.gov/


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