General Surgery · Year 3 · from General Surgery

Case 3: Pancreatic Pseudocyst

Patient Demographics

  • Age: 52 years
  • Sex: Male
  • Occupation: Construction worker

Chief Complaint

"I have pain and fullness in my stomach that won't go away since my pancreatitis 2 months ago."

History of Present Illness

The patient was hospitalized 8 weeks ago with acute alcoholic pancreatitis. He was treated conservatively and discharged after a 7-day hospital stay. Since discharge, he has had persistent epigastric pain, early satiety, and occasional nausea. He reports feeling a fullness in his upper abdomen. He has been unable to eat normally and has lost 5 kg. He stopped drinking alcohol after his hospitalization.

Past Medical History

  • Acute alcoholic pancreatitis (8 weeks ago)
  • Alcohol use disorder (now abstinent)
  • Hypertension

Physical Examination

  • Vitals: Normal
  • General: Thin male, appears uncomfortable
  • Abdomen:
  • Palpable, tender mass in epigastrium
  • Non-pulsatile
  • No peritoneal signs
  • Mild epigastric distension

Laboratory Results

  • WBC: 8,200/μL
  • Hemoglobin: 12.8 g/dL
  • Amylase: 168 U/L (mildly elevated)
  • Lipase: 124 U/L (mildly elevated)
  • Liver function tests: Normal
  • CA 19-9: Normal

Imaging

CT Abdomen with contrast:

  • 10 cm well-defined, round, fluid-filled collection in lesser sac
  • Thick, enhancing wall (>6 weeks old - mature wall)
  • Adjacent to stomach and pancreatic body
  • No solid component
  • No gas within collection
  • Main pancreatic duct appears normal
  • Consistent with mature pancreatic pseudocyst

MRI/MRCP:

  • Confirms pseudocyst
  • No communication with main pancreatic duct visible
  • No pancreatic duct stricture or dilation

Diagnosis

Symptomatic pancreatic pseudocyst (>6 weeks, mature wall)

Indications for Intervention

  • Symptomatic (pain, early satiety, nausea)
  • Size >6 cm (risk of complications)
  • Persistent symptoms despite conservative management

Treatment Options Discussed

  1. Endoscopic drainage: EUS-guided cystogastrostomy (preferred if anatomy favorable)
  2. Surgical drainage: Cystogastrostomy or Roux-en-Y cystojejunostomy
  3. Percutaneous drainage: Generally avoided (risk of external fistula)

Patient referred for endoscopic evaluation.

EUS-Guided Cystogastrostomy

  • EUS confirmed direct apposition of pseudocyst to stomach
  • Transmural puncture and tract creation
  • Lumen-apposing metal stent (LAMS) placed
  • 150 mL of dark, non-purulent fluid drained
  • Fluid analysis: High amylase (12,000 U/L), no bacteria

Post-Procedure Course

  • Pain improved significantly
  • Tolerating regular diet within 48 hours
  • Discharged POD 2

Follow-up

  • CT at 4 weeks: Pseudocyst collapsed to 2 cm
  • CT at 8 weeks: Complete resolution
  • Stent removed at 8 weeks via endoscopy
  • Alcohol abstinence maintained

Chronic Pancreatitis Evaluation

  • Given alcoholic etiology, patient counseled about chronic pancreatitis risk
  • Endocrine/exocrine function monitoring
  • Alcohol cessation essential

Teaching Points

  1. Pseudocyst forms >4 weeks after acute pancreatitis (encapsulated collection)
  2. Distinguished from walled-off necrosis (WON) by contents (fluid vs. necrosis)
  3. Most pseudocysts resolve spontaneously; intervene if symptomatic or complicated
  4. Mature wall (>6 weeks) required for drainage procedures
  5. Endoscopic drainage preferred when pseudocyst abuts stomach/duodenum
  6. Pseudocyst communication with pancreatic duct affects treatment
  7. Address underlying etiology (alcohol cessation crucial)

Clinical Image

Image Description: CT scan demonstrating a large, well-defined pancreatic pseudocyst in the lesser sac adjacent to the stomach. The collection has a mature, enhancing wall and homogeneous fluid contents, characteristic of a pseudocyst more than 4 weeks after acute pancreatitis.

Attribution: Image from Wikimedia Commons. Source: https://commons.wikimedia.org/wiki/Category:Pancreatic_cancer

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