2. Normal Anatomy by CT
Pancreas arcing
anteriorly over spine
Head adjacent to
duodenum
Tail extending toward
spleen
Splenic vein posterior to
body and tail
Portal vein confluence
immediately posterior &
left of pancreatic neck
3. Normal Morphology by CT
Pancreatic acini → lobulated contour
No capsule
AP dimensions
Head 2-2.5 cm
Body and tail 1-2 cm
Pancreatic duct
Maximal diameter 3 mm in adults (5 mm in elderly)
Empties into ampulla of Vater, along medial aspect of
2nd portion of duodenum
5. What is a pancreatic
pseudocyst?
A pancreatic pseudocyst is a collection
of fluid around the pancreas. The fluid
in the cyst is usually pancreatic juice
that has leaked out of a damaged
pancreatic duct. Pancreatic pseudocysts
arise after acute pancreatitis or chronic
pancreatitis. In some patients the
pseudocyst may develop soon after an
attack of acute pancreatitis. Often the
patient can present many weeks or
months after recovery from of an attack
of acute or chronic pancreatitis.
6. How do patients present with
pancreatic pseudocysts?
The common symptoms that patients present
are pain in the abdomen, the feeling of bloating
or poor digestion of food, a deep ache in the
abdomen or complications related to the
pseudocyst such as infection of the pseudocyst
with a pancreatic abscess, bleeding into the
pseudocyst or blockage of parts of the intestine
by the pseudocyst.
7. 28 year-old man with pseudocyst
Image demonstrates a pseudocyst (arrow) in the tail of the pancreas
surrounded by a thick enhancing wall. The lesion appears heterogeneous
with central areas of higher attenuation, which is suggestive of fresh
hemorrhage. Note infiltration (arrowheads) of the peripancreatic fat.
8. How are pancreatic
pseudocysts diagnosed?
The diagnosis is usually made by a CT
scan. A typical picture is seen on CT of a
fluid filled mass around the pancreas. It
is important to note that in some
patients, cystic tumors such as
mucinous cystadenoma may look
exactly like a pseudocyst. An evaluation
by an experience radiologist and a
surgeon to evaluate the cyst is
important for appropriate care?
11. How are pancreatic
pseudocysts treated?
All cysts do not require treatment. In
many cases the pseudocysts may
improve and go away on their own. In a
patient with a small (less than 6cm) cyst
that is not causing any symptoms,
careful observation of the cyst with
periodic CT scans is indicated. In a
significant number of patients the cyst
will get better and resolve. If a
pseudocyst is persistent over many
moths or causing symptoms then
treatment of the cyst is required.
12. Treatment of
pseudocysts
A number of different types of
treatments are available for
pseudocysts. The treatment of
pancreatic pseudocyst is complex and
should be performed in an institution
where a multidisciplinary team of
experienced pancreatic surgeons,
gastroenterologists and radiologist work
together. The optimal procedure
whether it is performed by the surgeon,
gastroenterologist or the radiologist is
therefore provided to the patient.
13. Surgical treatment of
pancreatic pseudocyst
The majority of patients who require
treatment for their pseudocysts are treated
by surgery. In the surgical procedure for the
treatment of pseudocyst a connection is
created between the cyst and an adjacent
intestinal organ to which the cyst is adherent
to such as the stomach. This connection
allows the cyst to drain into the stomach.
Since in many patients the cyst is formed by
continuous leakage of pancreatic juice into
the cyst this allows the pancreatic juice to be
rerouted into the intestine through the
connection.
14. Cystgastrostomy: In this surgical
procedure a connection is created between
the back wall of the stomach and the cyst
such that the cyst drains into the stomach.
Cystjejunostomy: In this procedure a
connection is created between the cyst and
the small intestine so that the cyst fluid
directly into the small intestine.
Cystduodenostomy: In this procedure a
connection is created between the
duodenum (the first part of the intestine)
and the cyst to allow drainage of the cyst
content into duodenum
15. The type of surgical procedure depends
on the location of the cyst. For cysts
that occur in the body and tail of the
pancreas either a cystjejunostomy or
cystgastrostomy is performed
depending on the location of the cyst in
the abdomen. For pseudocysts that
occur in the head of the pancreas a
cystduodenostomy is usually
performed.
16. Laparoscopic treatment for
pseudocysts
At USC we have developed a
laparoscopic procedure for treatment
of pancreatic pseudocysts. In this
procedure a cystjejunostomy or
cystgastrostomy is performed utilizing
minimal access techniques. Patients
recover rapidly from this procedure
usually discharged home on the
second day post-operatively.
17. Drainage of the pseudocyst
by a radiologist:
In this procedure a radiologist inserts a thin
needle into the pseudocyst under guidance
with an CT x-ray and to drain all the fluid.
While sometimes this technique is successful,
often this technique may give rise to a
significant number of complications such as
persistent leakage from the drain that the
radiologist places to drain the cyst over
many weeks or months, infection of the
pseudocyst and repeated procedures to have
the drain changed. Because of the multiple
problems associated with this treatment we
seldom recommend this treatment for
drainage of pseudocyst.
18. Drainage of the pseudocyst
by endoscopic techniques
In this procedure a gastroenterologist drains the
pseudocyst through the stomach by creating a small
opening between the cyst and the stomach during
endoscopy. In selected patients this treatment can
successfully treat pseudocyst. The disadvantage of this
technique is that if there is dead tissue in the
pseudocyst cavity or if the cyst is very large then
infection or recurrence of pseudocyst with this
technique may occur.
Insertion of a pancreatic stent: In this technique the
gastroenterologist may insert a drain into the cyst
during a procedure called ERCP. If the drain is placed
directly into the cyst then the fluid from the cyst is
drained into the intestine through this tube.
19. Outlook (Prognosis)
The outcome is generally good with
treatment. It is important to make
sure that it is not a pancreatic cancer
that starts in a cyst, which has a
worse outcome.
21. A pancreatic abscess can develop if
the pseudocyst becomes infected.
The pseudocyst can break open
(rupture), which can be a serious
complication because shock and
excess bleeding (hemorrhage) may
develop.
The pseudocyst may press down on
(compress) nearby organs.
22. References
Forsmark CE. Pancreatitis. In:
Goldman L, Schafer AI, eds. Cecil
Medicine. 24th ed. Philadelphia, Pa:
Saunders Elsevier; 2011:chap 146.
Forsmark Ce, Baillie J. AGA Institute
Technical Review on acute
pancreatitis. Gastroenterology.
2007;132:2022-2044.
