Sample Question

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CASE:

A 48-year-old Caucasian man presents with severe epigastric pain radiating to the back after a bout of drinking. Two weeks later, a repeat ultrasound showed a round thin-walled hypoechoic lesion near the pancreas tail measuring 4 cm in its largest diameter and with some calcifications in its walls. MRCP visualized a communication between this cavity and the pancreatic duct consistent with the diagnosis of pancreatic pseudocyst.

STEM:

What is the most appropriate next step in management?

ANSWER CHOICES:

  • a. Refer for sphincteroplasty.
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  • b. Perform angiography with coil embolization.
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  • c. Refer for a Puestow procedure.
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  • d. Refer for ERCP and transpancreatic drainage of the cyst.
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  • e. Refer for endoscopic ultrasound (EUS)-guided transgastric drainage.
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  • f. Observation only
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    EXPLANATION

    Pancreatic pseudocysts complicate about 10% of attacks of acute pancreatitis. A pseudocyst is formed when pancreatic fluid leaks and is confined by organs adjacent to the pancreas. Eventually, a fibrous wall forms around the collection. Most cysts regress spontaneously over a period of several weeks, but in some cases, complications such as bleeding, abscess formation, and intractable pain may occur. Therefore, observation is the best approach for most patients.

    Several interventional approaches—surgical, radiologic, and endoscopic (ERCP and transpancreatic drainage or EUS-guided transgastric drainage)—may be attempted if spontaneous resolution does not occur or complications warrant; internal drainage procedures are preferred to external approaches. Indications for intervention are intractable pain, expanding lesions, and infection.

    Sphincteroplasty is used to treat scarring of the pancreatic duct sphincter or sphincter of Oddi, which usually occurs as a result of chronic pancreatitis. It is not a treatment for a pancreatic pseudocyst.

    CT angiography is useful if there is suspicion of a pancreatic pseudoaneurysm, in which case coil embolization may be considered.

    A Puestow procedure is a surgical procedure that involves the creation of a side-to-side anastomosis of the pancreatic duct and the jejunum. It is used sometimes as a treatment for chronic pancreatitis, but not for a pseudocyst.

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    REFERENCES

    1. Brun A, Agarwal N, Pitchumoni CS. Fluid collections in and around the pancreas in acute pancreatitis. J Clin Gastroenterol. 2011;45(7):614-25.
    2. Jani N, Bani Hani M, Schulick RD, Hruban RH, Cunningham SC. Diagnosis and management of cystic lesions of the pancreas. Diagn Ther Endosc. 2011;478913.
    3. Tenner S, Baillie J, Dewitt J, Vege SS. American College of Gastroenterology guideline: management of acute pancreatitis [published correction appears in Am J Gastroenterol. 2014;109(2):302]. Am J Gastroenterol. 2013;108(9):1400-1415.
    4. Sonnenday CJ. Disorders of the Exocrine Pancreas. In: Hammer GD, McPhee SJ, eds. Pathophysiology of Disease: An Introduction to Clinical Medicine. 7th ed. New York: McGraw-Hill; 2013.
    5. Fisher WE, Andersen DK, Windsor JA, Saluja AK, Brunicardi F. Pancreas. In: Brunicardi F, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Matthews JB, Pollock RE, eds. Schwartz's Principles of Surgery. 10th ed. New York: McGraw-Hill; 2014.
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