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An abdominal mass

This abdominal CT was taken in a 25 year old man 6 weeks after an episode of abdominal pain.
1.  What does it show?
2. How could you manage this patients?

This abdominal CT scan shows a 10 cm diameter pancreatic pseudocyst adjacent to the posterior wall of the stomach. The episode of acute abdominal pain 6 weeks previously was acute pancreatitis due to alcohol excess. Pancreatic pseudocysts are fluid collections arising adjacent to the pancreas and often occurring in the less sac. They have a fibrous wall and are not true cysts as they lack an epithelial lining. They contain a fluid rich in pancreatic enzymes including amylase. At least one third of patients with acute pancreatitis develop acute fluid collections most of which resolve over a few weeks. Only those that are enlarging or become symptomatic require operative or surgical intervention or surgical intervention at this stage. Such early acute fluid collections should not be regarded as pseudocysts. Those persisting beyond 6 weeks are less likely to resolve spontaneously and are more prone to complications. It is these fluid collections that are true pancreatic pseudocysts. Symptoms of gastric outflow obstruction or persistent elevation of serum amylase may suggest the diagnosis. The exact time appropriate for conservative management is controversial.

Pancreatic fluid collections can be identified and followed up with ultrasound. Abdominal CT scan will allow assessment of the cyst in relation to adjacent structures. The use of endoscopic ultrasound has attracted recent interest particularly in as means of assessing the relationship of the cyst wall to the stomach prior to endoscopic drainage. ERCP will allow identification of any abnormality of the pancreatic duct and identify any fistulae between the duct and the cyst. Dependent on the findings seen at ERCP one of three treatment options may be appropriate

  • Percutaneous aspiration
  • Endoscopic drainage - transpapillary or transmural
  • Surgical drainage - cystogastrotomy or cystojejunostomy.

Percutaneous aspiration under ultrasound or CT guidance is about 80% successful when there is no fistula between the cyst and pancreatic duct. If a fistula is present the outcome is less assured. Percutaneous aspiration is occasionally associated with the development of a pancreatic abscess, pancreatic fistula or haemorrhage. Surgery allows adequate internal drainage and the opportunity to biopsy the cyst wall to exclude a cystic neoplasm. A cholecystectomy and exploration of the common bile duct can also be performed if required. The mortality of all procedures is approximately equal but the recurrence rate is less after surgery.

Recent Papers

Beckingham I J, Krige J E J, Bornman P C et al. Endoscopic management of pancreatic pseudocysts. Br J Surg 1997; 84: 1638-1645.

Grace P A, Williamson R C N. Modern management of pancreatic pseudocysts. Br J Surg 1993; 80: 573-581.

Johnson C D. Timing of intervention in acute pancreatitis. Postgrad Med J 1993; 69: 509-515.

Moran B, Rew D A, Johnson C D. Pancreatic pseudocyst should be treated by surgical drainage. Ann R Coll Surg Eng 1994; 76: 54-58.

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