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, allowing the fluid to drain internally.

Key Considerations

• The size of the cyst (11 x 15 cm) and the presence of symptoms justify intervention, 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.
• Internal drainage is superior to external drainage, which carries higher risks of fistula formation, infection, and fluid/electrolyte imbalances.
• Conservative management would be inappropriate for a cyst of this size with ongoing symptoms.
• The procedure can be performed endoscopically or surgically, with endoscopic drainage being preferred when anatomically feasible due to lower morbidity, as suggested by the high level of agreement on the optimal approach for drainage 1.

Additional Recommendations

• Following drainage, the patient should be counseled on complete alcohol cessation, as continued alcohol use would significantly increase the risk of recurrence and complications.
• Pain management and pancreatic enzyme supplementation may be needed depending on the degree of pancreatic damage from the initial pancreatitis episode.
• Pre-drainage evaluation, including CECT or MRCP and occasionally prior EUS, is recommended to decide on the best approach for drainage 1.
• Prophylactic antibiotics are recommended and should be continued post-procedurally, and the use of fluoroscopy is recommended during EUS-guided pseudocyst 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 2, 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.