eMedicine Specialties > Gastroenterology > Pancreas

Pancreatic Pseudocysts

Author: Louis R Lambiase, MD, Associate Professor of Medicine, University of Florida College of Medicine; Chief, Division of Gastroenterology, Department of Internal Medicine, University of Florida Health Science Center/Jacksonville
Contributor Information and Disclosures

Updated: Mar 18, 2008

Introduction

Background

Single or multiple fluid collections that look like cysts on pancreatic imaging are often observed during acute pancreatitis. Because of increasing sensitivity of imaging modalities and improvements in technology providing enhanced therapeutic abilities, the questions of when and whether drainage should be performed and what modality should be used to drain the cysts are often asked. Strictly defining the type of fluid collection is very important when reviewing pancreatic fluid collections. The therapeutic approach is different depending on the type of collection.

Pseudocysts are best defined as a localized fluid collection that is rich in amylase and other pancreatic enzymes, that has a nonepithelialized wall consisting of fibrous and granulation tissue, and that usually appears several weeks after the onset of pancreatitis.

These characteristics contrast with those of acute fluid collections, which are more evanescent and are serosanguinous inflammatory reactions to acute pancreatitis. These collections are noted in moderate-to-severe pancreatitis. Acute fluid collections usually have an irregular shape and lack a well-defined wall. In general, they resolve in about 65% of cases.

Two other types of fluid collection should be considered. First, organized necrosis is actually devitalized pancreatic tissue that appears cystlike on CT scan, but it appears to be solid on other imaging modalities. Second, an abscess is an infected area of necrosis or fluid.

Pathophysiology

Pancreatic pseudocysts can be single or multiple. Multiple cysts are more frequently observed in patients with alcoholism, and they can be multiple in about 15% of cases. Size varies from 2-30 cm. About one third of pseudocysts manifest in the head of the gland, and two thirds appear in the tail. The fluid in pseudocysts has been well characterized as clear or watery, or it can be xanthochromic. The fluid in pseudocysts usually contains very high amounts of amylase, lipase, and trypsin, though the amylase level may decrease over time.

The pathogenesis of pseudocysts seems to stem from disruptions of the pancreatic duct due to pancreatitis and extravasation of enzymatic material. Two thirds of patients with pseudocysts have demonstrable connections to the pancreatic duct. In the other third, an inflammatory reaction is supposed to have sealed the connection so that it is not demonstrable. The cause of pseudocysts parallels the cause of acute pancreatitis; 75-85% of cases are caused by alcohol or gallstone disease–related pancreatitis. In children, pseudocysts and trauma are frequently associated.

Sex

The male predominance in the incidence of pseudocysts mirrors the male predominance in the incidence of pancreatitis.

Age

Pseudocysts may occur after pancreatitis in any age group. In children, pseudocysts are most likely observed after abdominal trauma. In elderly persons, take care not to confuse cystic neoplasms with pseudocysts.

Clinical

History

  • No specific set of symptoms is pathognomic of pseudocysts; however, consider the possibility of a pseudocyst in a patient who has persistent abdominal pain, anorexia, or abdominal mass after a case of pancreatitis.
  • Rarely, patients present with jaundice or sepsis from an infected pseudocyst.
  • Pleural effusion is also a common finding.

Physical

  • The sensitivity of physical examination findings is limited.
    • Patients very frequently have a tender abdomen.
    • Patients occasionally have a palpable mass in the abdomen.
  • Peritoneal signs suggest rupture of the cyst or infection.
  • Other possible findings include the following:
    • Fever
    • Scleral icterus
    • Pleural effusion

Causes

Acute or chronic pancreatitis or abdominal trauma causes pseudocysts. If no history of pancreatitis or trauma exists, the diagnosis must be carefully confirmed.

More on Pancreatic Pseudocysts

Overview: Pancreatic Pseudocysts
Differential Diagnoses & Workup: Pancreatic Pseudocysts
Treatment & Medication: Pancreatic Pseudocysts
Follow-up: Pancreatic Pseudocysts
Multimedia: Pancreatic Pseudocysts
References
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References

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Further Reading

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Keywords

pancreatic fluid collections, organized necrosis of the pancreas, pancreatic cysts, pancreatitis, abdominal trauma, pancreatic ducts, persistent abdominal pain, anorexia, abdominal mass, jaundice, sepsis, pleural effusion, scleral icterus, percutaneous catheter drainage

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Contributor Information and Disclosures

Author

Louis R Lambiase, MD, Associate Professor of Medicine, University of Florida College of Medicine; Chief, Division of Gastroenterology, Department of Internal Medicine, University of Florida Health Science Center/Jacksonville
Louis R Lambiase, MD is a member of the following medical societies: American Gastroenterological Association, American Pancreatic Association, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Medical Editor

David Greenwald, MD, Fellowship Program Director, Associate Professor, Department of Medicine, Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine
David Greenwald, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Simmy Bank, MD, Chair, Professor, Department of Internal Medicine, Division of Gastroenterology, Long Island Jewish Hospital, Albert Einstein College of Medicine
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Assistant Dean for Medical Curriculum, Associate Professor of Medicine, Division of General Internal Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law Medicine and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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