PSEUDOCYS TS OF PANCREAS.pptx

7/27/2019 PSEUDOCYS TS OF PANCREAS.pptx

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ETIOLOGY It is localized collection of pancreatic juice occurring

as a result of pancreatic inflammation,trauma,or ductobstruction.

This is distinguished from other types of pancreaticcysts by their lack of an epithelial lining.


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Their walls are composed by fibrous and granulationtissue derived from peritoneum,retroperitonealtissue,or the

serosal surface of adjacent viscera.

Pancreatic cyst are being recognized in over 10% ofcases of acute pancreatitis.


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PATHWAY OF PANCREATIC CYST Diffuse peripancreatic effusion,pancreatic

necrosis,liquefaction,swelling which leads to acutepseudocyst and finally encapsulation occur(maturation).

Acute pseudocysts may occur after acute pancreatitisof any etiology.


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As a consequence of the necrotizing effect of pancreas,duct disruption with leakage of pancreatic juice intothe surrounding tissues.

Since there is no natural barrier to this fluid in theretroperitoneum,acute pseudocysts may locate anywhere from the mediastinum to the scrotum.


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Histories usually present in a case of pseudocyst are

-H/O acute abdominal pain suggestive of acute

pancreatitis. -H/O trauma

H/O chronic abdominal pain

-H/O alcoholism

H/O jaundice

due to pressure from pseudocyst


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Clinical features Epigastric mass

The upper limit may not be palpable

It is resonant to percussion(because of the overlyingstomach)

There is no movement with respiration(minimalmovement may be there)


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LOCATION Traumatic pancreatic pseudocysts are caused by duct

disruption secondary to blunt trauma.

The duct is usually injured where it crosses thevertebral column,and therefore these cysts tend tooccur anterior in the body of the gland.


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Usually the locations of the pseudocyst are

Lesser sac

Neck Mediastinum

Pelvis

The cysts are single in 85% cases and multiple in theremainder.


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TYPES OF PSEUDOCYST The pseudocyst may be

Acute pseudocyst

Chronic pseudocystAnother classification is

Post necrotic-following attack of necrotizingpancreatitis

Peripancreaticassocated with chronic pancreatitis

Intrapancreatic cyst- in advanced chronicpancreatitis(majority in the head of pancreas)


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Acute pseudocyst is a collection arising in associationwith an episode of acute pancreatitis of > 4 weeksduration and surrounded by well-defined wall ofgranulation or fibrous tissue.


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Chronic pseudocyst is a collection arising inassociation with chronic pancreatitis and surroundedby a well defined wall without antecedent episode ofacute pancreatitis.

It may also occur in trauma victims(after a blow)andalcoholics.


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In chronic pancreatitis, it appears that the ductrupture, or strictures with subsequent blow out of

the pancreatic duct. Because the pancreatic parenchyma is firm and

fibrotic, chronic pseudocysts commonly arelocated within the substance of the gland.


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Investigations Serum amylase-elevated (if serum amylase remain

elevated for 3 weeks, will have pseudocyst)

Leucocytosis

(about 50% of patients) Bilirubin elevated (suggestive of biliary obstruction)

CT scan is diagnostic study of choice(the size,shapeof the cyst and its relationship to other viscera can be

seen)


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In CT scan-Acute cysts are irregular in shape, chroniccysts are circular,

An enlarged pancreatic duct may be demonstreted inchronic pancreatitis.

A dilated CBD would suggest biliary obstructionneither from the cyst or as a result of pancreatitis.


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USG-to follow changes in size of acute pseudocyst and tostudy the gall bladder.

ERCP Not done routinely (if CT shows ductalabnormalities and if LFT is abnormal.)

ENDOSCOPIC RETROGRADE CHOLANGIOGRAPHYdemonstrate abnormalities of the pancteatic duct in up to90% of the patients with pseudocysts.

Nearly two-third of pseudocysts communicate with thepancteatic duct. ERCP is very helpful in -managing chronic pseudocysts


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Upper GI series- to look for site of gastric or duodenalobstrucion. The cyst will push the stomach wallanteriiorly


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Angiography is not useful for diagnosis of pseudocystsgenerally,however in patients whohave had bleedingcomplication from pseudocysts or those who have

portal hypertension,it may provide valuableinformation.


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TO DIFFRENTIATE PSEUDOCYST

FROM PANCREATIC RETETION CYST Chronic pseudocysts are impossible to distinguish

clinically from pancreatic retention cysts which areformed by progressive dilatation of a pancreatic duct

distal to an obstruction and also arise in the setting ofchronic pancreatitis.


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For practical purposes, the only difference betweenpseudocysts and retention cysts is the presence of anepithelial lining in the retention cyst.

Even this lining,however, may become flattened ordestroyed by inflamation and high intracysticpressure, further blurring the distinction betweenthese two entities.


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DIAGNOSIS Pancreatic pseudocysts should be suspected in

patients with acute pancreatitis whose symptoms failto resolve within 7 to 10 days or in patients with

chronic pancreatitis who complain of persistent painnausea or vomiting.


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According to Crass and Becker,epigastric pain is thepresenting complaint in 90% of patients.

Nausea and vomiting are present in nearly half of thepatients and weight loss is present in 40%.

As many as 60% of patients have an epigastric massand fever and jaundice may also be part of the

presentation.


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The absence of a mass does not exclude the diagnosisof pseudocysts,since even large pseudocysts can behidden by the costal margin.

While persistent hyperamylasemia following an attackof acute pancreatitis is a clue to the presence ofpseudocyst formation, it is present only 50% of thetime.


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There is no other laboratory test that is helpful in thediagnosis of pseudocysts.

The most reliable way of making the diagnosis is byultrasound or CT scanning.

Hessel found ultrasound to be 90% accurate and98%specific when the could be visualized.

Unfortunately,gas obscures the pancreas in nearly one-third of patients with pancreatitis.


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CT scans have increased sensitivity and specificity andprovided additional information about retroperitonealextension of f luid collection and the relationship

between cysts and adjacent enteric lumen that is notavailable from ultrasound.

Therefore,scanning is the is the preferred initial testfor detection of pseudocysts..


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DIFFERENTIAL DIAGNOSIS Pancreatic abcess

Pancreatic carcinoma

Neoplastic cyst-cystadenoma or cystadenocarcinoma Other epigastric masses


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NATURAL HISTORY Only when a collection persists beyond 3 weeks

showed it be considered a true pseudocyst.

Fluid collection may resolve by spontaneoustransperitoneal reabsorpton, decompression of thecollection into the pancreatic duct,or erosion of a cystinto a hollow viscus with subsequent cyst-enteric -fistula formation or rarely,by free rupture into theperitoneal cavity.


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Certain features indicate that it is unlikely to resolvespontaneously. They are

-Cysts larger than 4 to 6 cm

-Cyst that fails to show decrease in size during a 3 to 4week period of observation.

-Patient with multiple cysts

Chronic pseudocyst


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COMPLICATIONSAcute pancreatic pseudocysts that fail to resolve

spontaneously and chronic pseudocysts requiredrainage or excision.

IF,left untreated,they are liable to cause complicatonssuch as

Infection,

Obstruction, Bleeding or

Rupture.


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MANAGEMENT Since all fluid collection are not pseudocysts and not

all pseudocysts have the same natural history.

For acute cysts wait for 4 to 6 weeks from time ofdiagnosis for cyst wall maturity to occur.

Chronic pseudocysts can be drained immediately

Infected pseudocysts require external drainage

without delay.


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SURGICAL PROCEDURES There is no one surgical procedure appropriate for all

pseudocysts.

Drainage procedures generally are preferred overresection because they presrve pancreatic function,technically easier, and have a lower mortality rate.

Internal drainage is the preferred mathod of

decompression than with external drainage.


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INDICATION FOR INTERVENTION IN

PSEUDOCYST Persisting pain

Pressure effects caused by increasing size

Cysts of >6cm size

spontaneous resolution is there in40% of cases

Cysts of > 6weeks-- cyst wall is mature after 6weeks


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PERCUTANEOUS DRAINAGE

With the use of USG and CT guided percutaneousprocedures,it has become fashionable to treatpseudocysts by percutaneous means.


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EXTERNAL DRAINAGE-non surgical

procedureAlthough external drainage of pseudocysts has the

highest morbidity ,mortality, and recurrence rate ofthe various surgical options,it remains an extremely

useful and life saving opration. External drainge is the procedure of choice for grossly

infected cysts, cysts associated with haemorrhage,andthose cysts with a soft wall which will not hold sutures.


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INDICATIONFOR EXTERNAL

DRAINAGE Critically ill patients

Infected pseudocyst

Uncomplicated pseudocyst To shrink a huge pseudicyst occupying half of the

abdominal cavity


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COMPLICATION EXTERNAL

DRAINAGE

PANCREATICOCUTANEOUS FISTULA IN 20-30% OFPATIENTS.


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ENDOSCOPIC DRAINAGE

Chronic pseudocysts impinging on the gastric orduodenal wall may be drained endoscopically bycreating a cyst-enteric fistula.

Acute cyst should not be endoscopically drainedbecause its difficult to be certain that the cyst is

adherent to the gut. Complications: Bleeding from the cyst wall or leakage

of cyst into the peritoneal cavity.


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INTERNAL DRAINAGE In patients with mature cyst wall, internal drainage is

the best surgical option.

Mature cysts can be drained into thestomach,duodenum,or small bowel.The choice of theoperation is depends on the location of the pseudocyst.

Cysts adherent to the stomach are ideally drained by acystgastrostomy


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Cystduodenostomy should be performed forpseudocysts in the head of the pancreas that impingeon the duodenal wall.

Cystjejunostomy generally is employed for cysts in thebody and tail of the pancreas.


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Surprisingly the food will not go to the cyst cavity.

Recurrence rate: 10%

complication: Hemorrhage occurs rarely


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DISTAL PANCREATIC RESECTION Pseudocysts in the tail of the pancreas involving the

spleen are the most suitable lesions for distalresection.

ERCP in this situations may provide valuableinformation about the proximal pancreaticduct,helping to define the extent of resection.


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Treatement of pseudocyst

hemorrhageAngiographic embolization

Subsequent elective treatment of the pseudocysts

Emergency laparotomy and ligation of the bleedingvessel after opening the cyst,and drainage ofpseudocyst.

For lesion in the pancreatic head

pancreaticoduodenectomy may be required.


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THANK YOU ALL


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PSEUDOCYS TS OF PANCREAS.pptx