What is the management of a patient with a history of alcoholism and acute pancreatitis 3 months prior, now presenting with persistent epigastric pain and a 11 x 15 cm epigastric pseudocyst?

From the Guidelines

The management of an 11 x 15 cm epigastric cyst in a patient with a history of alcoholic acute pancreatitis and persistent epigastric pain would be internal drainage (option A). This approach is preferred for large pancreatic pseudocysts (which this likely represents) that persist beyond 6 weeks and are symptomatic, as indicated by the consensus guidelines on the optimal management in interventional EUS procedures 1. Internal drainage involves creating a connection between the pseudocyst and the gastrointestinal tract, typically through cystogastrostomy, cystoduodenostomy, or cystojejunostomy, depending on the anatomical location.

Key Considerations

• The patient's cyst size (11 x 15 cm) and persistence of symptoms after 3 months meet the criteria for drainage, as stated in the guidelines that acute pseudocysts should be drained if they persist for more than 4–6 weeks, have a mature wall, and are ≥6 cm in size, causing symptoms or complications 1.
• EUS-guided drainage is considered the optimal drainage approach in uncomplicated pseudocysts that are located adjacent to the stomach or duodenum, with a high level of evidence supporting its use 1.
• Pre-drainage evaluation, including CECT or MRCP and occasionally prior EUS, is recommended to decide on the best approach for drainage 1.

Recommendations

• Internal drainage is the recommended approach for this patient, given the size of the cyst and the presence of symptoms.
• The patient should also receive counseling for alcohol cessation, nutritional support, and pain management as part of comprehensive care to prevent recurrent pancreatitis episodes and further complications.
• Prophylactic antibiotics are recommended and should be continued post-procedurally, as suggested by the guidelines 1.
• Multidisciplinary involvement, including an endoscopist, interventional radiologist, and surgeons, is crucial in managing complicated cases to decide on the best approach to drainage 1.

From the Research

Management of Epigastric Cyst

The patient has a history of acute pancreatitis and currently presents with an epigastric cyst of 11 x 15 cm. The management of this condition can be considered based on the following options:

• Internal drainage: This approach is supported by studies 2, 3, 4, which suggest that internal drainage can be an effective method for managing pancreatic pseudocysts, especially for symptomatic patients.
• Conservative treatment: According to study 5, most pseudocysts resolve spontaneously with supportive care, but this approach may not be suitable for larger cysts or those causing symptoms.
• External drainage: This option is mentioned in study 4 as a possible approach for giant pancreatic pseudocysts, but it may not be the preferred initial method of management.

Considerations for Management

When deciding on the management approach, the following factors should be considered:

• Size of the cyst: Larger cysts are more likely to be symptomatic or cause complications 5.
• Presence of symptoms: Symptomatic pseudocysts require intervention 5, 6.
• Patient's medical history: The patient's history of acute pancreatitis and alcohol use should be taken into account when determining the best course of treatment.
• Availability of expertise: The management approach may vary based on local expertise, as mentioned in study 5.

Drainage Methods

Different drainage methods can be considered, including:

• Endoscopic drainage: This approach is becoming the preferred method for managing pancreatic pseudocysts due to its high success rate and low complication rate 5, 3, 4.
• Percutaneous catheter drainage: This method is mainly used for infected pseudocysts 2, 3.
• Surgical drainage: Open internal drainage and pseudocyst resection are surgical techniques with high success rates, but also higher morbidity and mortality compared to endoscopic treatment 2, 3.