pancreatic pseudocysts : definition and classification.

1. Dr Karrar Adil

2. Definitions :
 is a collection of amylase-rich fluid enclosed in a well-
defined wall of fibrous or granulation tissue.
 It typically arises following an attack of acute
pancreatitis, but can develop in chronic pancreatitis
or after pancreatic trauma.
 Formation of a pseudocyst requires 4 weeks or more
from the onset of acute pancreatitis.
 It is often single, but may be multiple and more than
half will be found to have a communication with the
main pancreatic duct.

3. Today, the most used definitions differentiate
between peripancreatic fluid collections, pseudocysts
and pancreatic abscesses are in the Atlanta
classification system for acute pancreatitis :
• Acute Fluid Collections: occur early in the course
of acute pancreatitis, are located in or near the
pancreas, and always lack a wall of granulation or
fibrous tissue.
• Pancreatic Abscess: is a circumscribed
intraabdominal collection of pus, usually in
proximity with the pancreas, containing little or no
pancreatic necrosis, arising as the consequence of
acute pancreatitis, trauma or chronic pancreatitis.

4. • Acute Pseudocysts: are constituted by
pancreatic juice enclosed by a wall of fibrous
or granulation tissue, arising as a
consequence of acute pancreatitis or
pancreatic trauma.
• Chronic Pseudocysts: are constituted by
pancreatic juice enclosed by a wall of fibrous
or granulation tissue, arising as a
consequence of chronic pancreatitis and
lacking an antecedent episode of acute
pancreatitis.

5. Contrast enhanced CT image,
obtained at admission, reveals acute
peripancreatic fluid collection (F)
Contrast enhanced CT image,
obtained 6 weeks after the onset of
acute attack, reveals a pseudocyst
(Ps).

6. Classifications
 Sarles classification
 D’Egidio classification
 Nealon and Walser classification

7. Sarles classification of pancreatic
pseudocyst :
An early proposed classification of pancreatic
pseudocysts depended on the association with
acute or chronic pancreatitis.
• Necrotic pseudocyst in acute pancreatitis.
• Retention cyst in chronic pancreatitis.
• lntrapancreatic retention due to pancreatic duct
dilatation.
• Extrapancreatic retention cyst due to rupture into
peripancreatic tissues.

8. The D’EGIDIO Classification of
Pancreatic Pseudocyst :
 proposed by D’Egidio and Schein in 1991.
 based on the underlying etiology of pancreatitis
(acute or chronic), the pancreatic ductal
anatomy, and the presence of communication
between the cyst and the pancreatic duct.
 identified three distinct types of pseudocysts :

9. • Type I :
 After an attack of acute pancreatitis.
 Normal duct anatomy;
 duct-cyst communication : no fistula/communication.
• Type lI :
 After an attack of acute on chronic pancreatitis.
 Abnormal duct anatomy without stricture;
 duct-cyst communication : 50% chances of fistula.
• Type Ill :
 After an attack of chronic pancreatitis,
 abnormal anatomy with stricture;
 duct-cyst communication : always communicating.

10. Nealon and Walser ERCP
classification :
 This classification system based solely on
pancreatic duct anatomy.
 on the postulate that the main pancreatic
duct determines the type and course of the
pseudocysts.
 Published in 2002, so far, this classification
had limited use.

11. • Type I : normal duct / no communication with cyst.
• Type II : normal duct with duct-cyst communication.
• Type III : otherwise normal duct with stricture and no duct-cyst
communication.
• Type IV : otherwise normal duct with stricture and duct-cyst
communication.
• Type V : otherwise normal duct with complete obstruction.
• Type VI : chronic pancreatitis, no duct-cyst communication.
• Type VII : chronic pancreatitis with duct-cyst communication.

12. Type I Type II Type III Type IV
Type V Type VI Type VII

13. Thank you …