Cyst drainage

[Guest guest]

Dear Rupesh and all members,

Now you know my mother's case. Hence I will not repeat it.

Now our Dr. says that the Cyst is still there. It's size is 80mm x 50mm. Though,

since last two months it has reduced by @ half.

Dr. says that we should now drain it gastroscopely. ( Gastroscopic drainage ).

What is your opinion? Pl. note that she has lost @ 20 kg in last three months

and does'nt have apetite, has nautia etc.

In view of this shall we go in for drainage? Also she needs to remove Gakk

bladder. We dont know whether Dr. will also remove it or not.

I am giving her story as on Nov. 2004 as under. Although She is now better and

having above problems.

Please advice.

Thanks.

-- Satish, India

Story on 28/11/2004

Let me introduce myself. I am son of a mother who had Attack of Pancreatitis

on 3rd Nov. 2004.

As I have access to Internet & can converse on mails I am becoming member of

PAI.

My mother is @ 63 Year and have gall blader stones. Dr. had advised removal

of it but due to BP problems she was not operated. Lateron we never took it

seriously which appears to be big mistake!

Now after going thr " usual stuff in Hospital she has been discharged since

last 5 days. She is having nausiatic feelings and does not feel likke eating

/ drinking anything. She also had fever for one day after discharge. She

even had fever in Hospital. Now no fever. But she is having lot of weekness

and feels sick. No pains in stomoch.

What is your opinion and advise? When will she recover? What diet she should

take now? When should we remove her Gall Bladder? Will that stop this

problem forever?

Hope Rupesh has gone thr " similar and recovered hence my mother will also do

so. Rupesh, can you please answer my questions?

Thanks. Regards.

-- Satish Suryawamshi

SANGLI, INDIA

91-233-2303533

[Guest guest]

Dear Satish,

While I can not tell you what to do regarding your mother's pseudocyst, I can

tell you that here in the U.S., it would be considered an appropriate

procedure to laproscopically drain a pseudocyst of that size. For the last few

months, the directions that the medical professionals have given you for your

mother's care have been very much the same that would have been given

here in the U.S. They advised you that it would be necessary to wait for a few

months to allow the cyst to resolve some on it's own from it's previously huge

size. It has reduced now to a size that is more suitable for safe gastroscopic

drainage that should allow for a successful procedure. Since it was so large

in the beginning, it would take a reasonably long period of time to reduce on

it's own, so I think good progress has been made.

Since it appears that the gallstones formed by your mother's gallbladder were

the root of the problems that caused her pancreatitis to begin with, it would

appear logical that the organ that caused all these problems should be

removed. If the gallbladder wasn't removed, in all probability, it could again

create stones that would obstruct the ducts again, and the whole process

would repeat itself over again. This is why they advise for its removal.

Everything that you've told us that the doctor's have advised you sounds to

be like suitable, conservative medical practice for a woman of your mother's

age. I would think that you should feel confident in the advice these doctor's

have given you, and to trust them to continue with her drainage as planned,

removal of her gallbladder, and her continuing health care. You must

understand that I am not a doctor, and have no professional experience, only

that experience I've had as a patient with chronic pancreatitis with two

pseudocysts, and knowledge gained from reading and research.

I'm including two medical articles for you to look at, one is about pancreatic

pseudocysts, and the other is about drainage of cysts.

With love, hope and prayers,

Heidi

Heidi H. Griffeth

www.pancassociation.org/anthology#Heidi.html

Bluffton, SC

SC State & SE Regional Representative

Pancreatitis Association, International

Note: All comments or advice are personal opinion only, and should not be

substituted for professional medical consultation.

Pancreatic Pseudocysts

Background: Single or multiple fluid collections giving the appearance of cysts

on pancreatic imaging often are seen during acute pancreatitis. Because of

the 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 often are 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, has a nonepithelialized wall that

consists of fibrous and granulation tissue, and usually appears several weeks

after the onset of pancreatitis.

This is in contrast with acute fluid collections, which are more evanescence in

nature and are serosanguinous inflammatory reactions to acute pancreatitis.

These are seen in pancreatitis that is more moderate to severe. They usually

have an irregular shape and lack a well-defined wall. In general, these

resolve in about 65% of cases.

Two other types of fluid collection should be considered. First, organized

necrosis actually is pancreatic tissue that is devitalized and 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 seen more frequently in alcoholic disease, and they can be multiple

in about 15% of cases. Size can vary from 2-30 cm. About one third of

pseudocysts present in the head of the gland, and two thirds present in the

tail. The fluid in pseudocysts has been well characterized as either clear or

watery, or it can be xanthochromic. The fluid in pseudocysts usually contains

very high amounts of amylase, lipase, and trypsin, though amylase 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 one 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. A

frequent association exists between pseudocysts and trauma in children.

Sex: A male predominance exists in the incidence of pseudocysts that mirrors

the male predominance in the incidence of pancreatitis.

Age: Pseudocysts may occur after pancreatitis in any age group. In children,

pseudocysts most likely are seen after abdominal trauma. In elderly persons,

take care not to confuse cystic neoplasms with pseudocysts.

CLINICAL Section 3 of 11   

History:

* No specific set of symptoms that would lead a clinician to diagnosis a

pseudocyst exists; however, suspect 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 also is a common finding.

Physical:

* The sensitivity of physical examination is limited.

* Very often, patients have a tender abdomen.

* Occasionally, patients 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

needs to be carefully confirmed.

Lab Studies:

* Serum tests have limited utility.

* Amylase and lipase often are elevated but may be normal.

* Bilirubin and liver function tests (LFTs) may be elevated if the biliary tree

is

involved.

* Analysis of the cyst fluid may help differentiate pseudocysts from tumors.

Attempt to rule out tumors in any patient who does not have a clear-cut

history of pancreatitis.

* Carcinoembryonic antigen (CEA) and carcinoembryonic antigen-125

(CEA-125) tumor markers are low in pseudocysts and high in tumors.

* Fluid viscosity is low in pseudocysts and high in tumors.

* Amylase usually is high in pseudocysts and low in tumors.

* Cytology occasionally is helpful in diagnosing tumors, but a negative result

does not exclude tumors.

Imaging Studies:

* Abdominal ultrasound: While cystic fluid collections in and around the

pancreas may be visualized via ultrasound. The technique is limited by

operator skill, the patient's habitus, and overlying bowel gas. As such, it is

not

the procedure of choice for diagnosis.

* CT scan of the abdomen

* CT scan is the imaging criterion standard. It has a sensitivity of 90-100%

and is not operator dependent.

* The usual finding on CT scan is a large cyst cavity in and around the

pancreas.

* Multiple cysts may be present.

* The pancreas may appear irregular or have calcifications.

* Pseudoaneurysms of the splenic artery, bleeding into a pseudocyst, biliary

and enteric obstruction, and other complications may be seen on CT scan.

* The CT scan provides a very good appreciation of the wall thickness of the

pseudocyst, which is useful in planning therapy.

* Endoscopic retrograde cholangiopancreatography

* Endoscopic retrograde cholangiopancreatography (ERCP) is not necessary

in diagnosing pseudocysts; however, it is useful in planning drainage strategy.

* A study by Neil et al looking at the utility of ERCP and the treatment of

pseudocysts and acute pancreatitis reported that 35% of the time a change in

management occurred after the ERCP findings in pseudocysts were

evaluated. Therefore, many authors recommend performing an ERCP before

contemplated drainage procedures.

* MRI

* MRI is not necessary for the diagnosis of pseudocysts; however, it is useful

in detecting a solid component to the cyst and differentiating between

organized necrosis and a pseudocyst.

* A solid component makes catheter drainage difficult; therefore, in the setting

of acute necrotizing pancreatitis with resultant pseudocyst, an MRI may be

very important before a planned catheter drainage procedure.

* Endoscopic ultrasound

* Endoscopic ultrasound (EUS) is not necessary for diagnosis but is very

important in planning therapy, particularly if endoscopic drainage is

contemplated.

* A gastric wall with a thickness greater than 1 cm next to the cyst tends to

predict a poor outcome with endoscopic drainage.

* EUS also may be helpful in detecting small portal collaterals from otherwise

undetected portal hypertension that may increase bleeding risks with

transmural drainage.

* Transmural drainage may only be performed when the symptomatic

pseudocyst is positioned next to the gut wall.

Histologic Findings: Histology varies with age because older cysts have

thicker walls with increased collagen. The etiology of the cyst does not

change the histology.

TREATMENT    

Medical Care: The goal of therapy should be avoidance of complications.

* About 10% of pseudocysts become infected.

* Pseudocysts also can rupture. A controlled rupture into an enteric organ, at

times, can cause GI bleeding. A free rupture into the peritoneal cavity

produces abdominal pain and, on rare occasions, peritonitis or even death.

* Most pseudocysts resolve without interference and only require supportive

care.

* Several studies have indicated that the size of the cyst and length of time

the cyst has been present are poor predictors of complications. In general,

larger cysts are more likely to become symptomatic or cause complications.

However, some patients with larger collections do well. Therefore, size of the

pseudocyst alone should not be an indication for drainage.

* Indications for drainage

* Complications

* Symptoms

* Concern about possible malignancy

Surgical Care: Drainage options include the following:

* Catheter drainage

* Percutaneous aspiration is useful only for diagnosis or as a temporizing

measure. It has a 54% failure rate and a 63% recurrence rate. Also, a

relatively high risk of infecting the pseudocyst exists with this technique.

* Percutaneous catheter drainage is the procedure of choice for treating

infected pseudocysts, allowing for rapid drainage of the cyst and identification

of any microbial organism. A high recurrence and failure rate exist, but

catheter drainage may be a good temporizing measure. It is contraindicated

in patients who are poorly compliant and cannot manage a catheter at home.

It also is contraindicated in patients with strictures of the main pancreatic

duct

and in patients with cysts containing bloody or solid material.

* Endoscopic drainage may be either transpapillary (via ERCP) or transmural.

Both modalities require careful patient selection to ensure success and

safety.

* Transpapillary drainage, while safer and more effective than transmural

drainage, requires cyst communication with the pancreatic duct. This

technique also may be technically challenging because it requires wire

passage and stenting through the pancreatic duct to the pseudocyst. The

success rate is about 80%, the recurrence rate is 10-14%, and in most series,

the complication rate (mainly pancreatitis) is approximately 13%.

* Endoscopic transmural drainage also is possible. This involves performing

an endoscopy and finding a bulge within the wall of the stomach or

duodenum caused by compression of the pseudocyst. Then, the cyst is

generally entered using a needle knife to cut through the gastric or

duodenum wall, and a series of pigtail stents are placed through the resulting

communication. The method has about an 82-89% success rate in very

experienced hands. The recurrent rate is between 6% and 18%. The

complication rate is 20%, with the most feared complication being bleeding.

* Surgical drainage is the criterion standard that all the therapies need to be

measured against.

* Internal drainage is the procedure of choice.

* In most series, a 3% mortality rate exists, and the complication rate is about

24%.

* The success rate tends to be between 85% and 90%.

Consultations: Management of pseudocysts requires a team approach. The

gastroenterologist, the surgeon, and the invasive radiologist must all work

together to determine the necessity, timing, and method of intervention.

Diet: Patients may eat a low-fat diet, as tolerated. Patients in whom eating

causes abdominal pain need either parenteral nutrition or enteral nutrition

through a percutaneously or endoscopically placed jejunal tube.

Activity: Activity as tolerated

Further Outpatient Care:

* Patients who have endoscopically placed stents must be monitored via

serial CT scans to observe resolution of the cyst. Stents may then be

removed endoscopically after resolution.

* Closely monitor patients with percutaneous drains for pain, infection, or

catheter migration. Remove the drain when drainage ceases.

Complications:

* Bleeding is the most feared complication. It is caused by the erosion of the

pseudocyst into a vessel.

* Suspect bleeding in any patient who has a sudden increase in abdominal

pain coupled with a drop in hematocrit or a change in vital signs.

* Therapy is emergent surgery or angiography with embolization of the

bleeding vessel.

* Do not perform a percutaneous or endoscopic drainage procedure under

any circumstances in patients with suspected bleeding into a pseudocyst.

* Suspect infection of the pseudocyst if the patients develop fever or an

elevated white blood cell count. Treat infection with antibiotics and urgent

drainage.

* GI obstruction, presenting with nausea and vomiting, is an indication for

drainage.

* The pseudocyst also can rupture.

* A controlled rupture into an enteric organ occasionally causes GI bleeding.

* A profound rupture into the peritoneal cavity, on rare occasions, causes

peritonitis and death.

Prognosis:

* Most pseudocysts resolve without interference, and patients do well without

intervention.

* If patients develop complications or need to have the cysts drained, the

outcome is much worse.

* The failure rate for drainage procedures is about 10%, the recurrence rate

is about 15%, and the complication rate is 15-20%

Patient Education:

* Patients who are being managed expectantly must be educated about the

warning signs for potential complications (eg, abdominal pain, fever), which

may indicate bleeding, fever, or pseudocyst rupture.

Satish wrote:

> Now our Dr. says that the Cyst is still there. It's size is 80mm x 50mm.

Though, since last two months it has reduced by @ half.

> Dr. says that we should now drain it gastroscopely. ( Gastroscopic drainage

). What is your opinion? Pl. note that she has lost @ 20 kg in last three

months and does'nt have apetite, has nautia etc.

> In view of this shall we go in for drainage? Also she needs to remove Gakk

bladder. We dont know whether Dr. will also remove it or not.