Pancreatic Pseudocysts and other compl

Question 1

capsule of a pseudocyst is composed of

Answer 1

collagen and granulation tissue, and it is not lined by epithelium.

Question 2

What percentage will have symptoms ?

Answer 2

50 %

Question 3

Diagnosis ?

Answer 3

> > CT or MRI.
EUS with FNA is indicated for patients in whom the diagnosis of pancreatic pseudocyst is not clear.

Characteristic features:
- high amylase levels
- absence of mucin
- low carcinoembryonic antigen (CEA) levels.

Question 4

When to observe ?

Answer 4

• asymptomatic patients
• pseudocysts smaller than 4 cm in diameter
• located in the tail
• no evidence of pancreatic duct obstruction or communication with the main pancreatic duct.

Question 5

Intervention ?

Answer 5

> > transgastric endoscopic drainage
transduodenal endoscopic drainage

> > in close contact (defined as <1 cm) with the stomach and duodenum

> > transpapillary drainage IF communicating with the main pancreatic duct.

> > For patients in whom a pancreatic duct stricture is associated with a pancreatic pseudocyst, endoscopic dilation and stent placement are indicated.

Question 6

Surgical Options ?

Answer 6

> > Pancreatic pseudocysts closely attached to the stomach should be treated with a cystogastrostomy

> > anterior gastrostomy
pseudocyst is located
drained through the posterior wall of the stomach using a linear stapler
The defect in the anterior wall of the stomach is closed in two layers

Question 7

Other Options

Answer 7

> > Pancreatic pseudocysts located in the head of the pancreas that are in close contact with the duodenum are treated with a cystoduodenostomy.

> > pseudocysts are not in contact with the stomach or duodenum:
- Roux-en-Y cystojejunostomy.
- Surgical cyst enterostomy is successful in achieving immediate cyst drainage in more than 90% of cases

Question 8

Complications

Answer 8

• bleeding : vascular erosion
• pancreaticopleural fistula pleural erosion
• bile duct and duodenal obstruction
• rupture into the abdominal cavity
• infection.

> > Percutaneous drainage is indicated only for septic patients secondary to pseudocyst infection because it has a high incidence of external fistula

Question 9

Pancreatic Ascites

Answer 9

• disruption of the pancreatic duct
• episode of AP, develop significant abdominal distention, and have free intraabdominal fluid
• . Diagnostic paracentesis typically demonstrates elevated amylase and lipase levels.
• Treatment consists of abdominal drainage combined with endoscopic placement of a pancreatic stent across the disruption.
• Failure of this therapy requires surgical treatment; it consists of distal resection and closure of the proximal stump

Question 10

Pancreaticopleural Fistulas

Answer 10

• Posterior pancreatic duct disruption into the pleural space
• large, left-sided pleural effusion caused by a pancreatic-pleural fistula
• Amylase levels above 50,000 IU in the pleural fluid confirm the diagnosis.
• Initial treatment requires chest drainage, parenteral nutritional support, and administration of octreotide.
• Persistent drainage should also be treated with endoscopic sphincterotomy and stent placement

Question 11

Vascular Complications

Answer 11

• The most common vessel affected is the splenic artery
• pancreatic elastase damages the vessels, leading to pseudoaneurysm formation
• . If possible, arterial embolization should be attempted to control the bleeding.
• Refractory cases require ligation of the vessel affected

Question 12

Splenic Vein Thrombosis ?

Answer 12

• Imaging demonstrates splenomegaly, gastric varices, and splenic vein occlusion
• most patients can be managed with conservative treatment
• Anticoagulation for splanchnic vein thrombosis related to pancreatitis has not been shown to improve recanalization Vs Observation
• Recurrent episodes of upper gastrointestinal bleeding caused by venous hypertension should be treated with splenectomy.