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
- Endoscopic drainage: EUS-guided cystogastrostomy (preferred if anatomy favorable)
- Surgical drainage: Cystogastrostomy or Roux-en-Y cystojejunostomy
- 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
- Pseudocyst forms >4 weeks after acute pancreatitis (encapsulated collection)
- Distinguished from walled-off necrosis (WON) by contents (fluid vs. necrosis)
- Most pseudocysts resolve spontaneously; intervene if symptomatic or complicated
- Mature wall (>6 weeks) required for drainage procedures
- Endoscopic drainage preferred when pseudocyst abuts stomach/duodenum
- Pseudocyst communication with pancreatic duct affects treatment
- 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