VGM hospital brings to you a series of case reports of common scenarios with treatment algorithms. In your busy schedule, we hope thses short notes will be refreshing and useful.

Pseudocyst of Pancreas

Pseudocyst of pancreas is a common entity encountered in clinical practice. Here is a short discussion about the same. Pancreatic pseudocysts most often develop after an episode of severe acute pancreatitis. They may develop in a patient with chronic pancreatitis. Asymptomatic pseudocysts need no treatment. The pseudocyst when large in size, could cause Gastric outlet obstruction or CBD obstruction. It may be the cause of pain in a patient with chronic pancreatitis. It can develop into a pseudoaneurysm.

It is also important to differentiate pseudocyst, from Walled off Pancreatic Necrosis which has significant debris and needs a different approach.

There are two approaches to drain a pseudocystsurgical and endoscopic drainage. Surgical cystojejunostomy or cystogastrostomy can be done laparoscopically also. Percutaneous drainage is not done nowadays due to increased morbidity.

CECT image of Pseudocyst of Pancreas

Endoscopic EUS guided cystogastrostomy is done through the stomach and duodenum. It is less invasive. Pseudocysts communicating with the PD (detected by MRCP) can be drained by a transpapillary approach of ERCP.

Here is a patient with a large pseudocyst which was drained by EUS guided drainage. 43 year gentleman presented with abdominal distension, vomiting since 2 months, decreased urine output since 2 days. He had the background of significant alcohol intake and had been admitted 3 months ago with acute pancreatitis for 20 days elsewhere and recovering from the episode, he had developed the distention.

EUS Guided Cystogastrostomy

On examination he appeared dehydrated, and emaciated. Abdomen was excessively distended and tense with fluid thrill. USG abdomen showed a large pseudocyst 30x14x11 cm with minimal debris. At presentation TC 28,000, Lipase- 150, Urea- 110, Creatinine- 4mg/dl. With hydration, renal failure improved and Cr improved to 1 mg/dl. EUS guided
cystogastrostomy was done under GA (GA is needed for protection of the airway, as there is a possibility of aspiration due to large volume of fluid from the pseudocyst after drainage). The cyst was visualized with linear echo endoscope.

The cyst wall and gastric wall was punctured using 19 G EUS needle, the guidewire was coiled in the cyst. Then a 6 Fr cystotome was advanced and the tract was formed over the guidewire.A 6-7-8 mm CRE balloon was used to dilate the tract.Two plastic stents were placed. The patient recovered well and there was no further vomiting. At two month followup the patient has gained weight and the size of the cyst is 7×1 cm.

Pancreatic pseudocysts are generally asymptomatic. Symptomatic pseudocysts are easy to treat by endoscopy. Here is an algorithm which we follow at VGM for treatment of patients with Pancreatic pseudocysts.