From the Guidelines
A hemorrhaging pancreatic pseudocyst causing abdominal pain requires immediate endoscopic ultrasound-guided drainage as the primary treatment, given its high success rate and low complication rate compared to other approaches. This approach is supported by the Asian EUS Group RAND/UCLA expert panel, which states that EUS-guided drainage is the optimal drainage approach in uncomplicated pseudocysts that are located adjacent to the stomach or duodenum, with a high evidence level 1. Prior to the procedure, the patient needs hemodynamic stabilization with IV fluids, blood transfusions if significant blood loss has occurred, and pain management with opioid analgesics like morphine 2-4mg IV every 4 hours as needed. Antibiotics such as piperacillin-tazobactam 3.375g IV every 6 hours should be administered to prevent infection, as recommended by the consensus guidelines on the optimal management in interventional EUS procedures 1.
Some key considerations for the procedure include:
- Pre-drainage evaluation with CECT or MRCP to decide on the best approach for drainage 1
- The use of fluoroscopy during EUS-guided pseudocyst drainage to improve precision and safety 1
- The insertion of one or two plastic pigtail stents to maintain the patency of the cystogastrostomy after EUS-guided drainage 1
- The potential need for adjunctive treatments, such as the insertion of a pancreatic ductal stent in patients with partially disrupted pancreatic ducts 1
Postoperatively, patients require close monitoring in an ICU setting, continued pain management, and gradual advancement of diet as tolerated. This aggressive approach is necessary because hemorrhage into a pseudocyst represents a life-threatening complication with high mortality rates if left untreated, as the bleeding can lead to hypovolemic shock and the large pseudocyst can cause compression of surrounding structures, worsening pain, and potential rupture. The use of percutaneous catheter drainage (PCD) may be considered as a temporizing measure prior to surgery, but it is associated with higher rates of reintervention, longer length of hospital stay, and increased number of follow-up abdominal imaging studies compared to endoscopic approaches 1.
From the Research
Treatment Options for Large Pancreatic Pseudocyst with Hemorrhage
- The management of a large pancreatic pseudocyst that has hemorrhaged and is causing abdominal pain requires a multidisciplinary approach, involving therapeutic endoscopists, interventional radiologists, and pancreatic surgeons 2.
- Three different strategies for pancreatic pseudocysts drainage are available: endoscopic (transpapillary or transmural) drainage, percutaneous catheter drainage, or open surgery 2, 3.
- Endoscopic drainage is becoming the preferred approach because it is less invasive than surgery, avoids the need for external drain, and has a high long-term success rate 2.
- However, in cases of hemorrhagic cysts, open surgery may be the treatment of choice, with options including distal pancreatectomy or marsupialization, which have low complication and mortality rates 4.
- Percutaneous continuous catheter drainage is also an option, with a low complication rate and the ability to reduce recurrence rates to less than 10% 3.
Considerations for Treatment
- The size of the pseudocyst and the presence of complications, such as hemorrhage, are key factors in determining the need for invasive drainage procedures 2.
- Patient preferences and the involvement of a multidisciplinary team should be considered in all cases 2.
- The natural history of the disease and the risk of complications, such as infection or gastric outlet obstruction, should also be taken into account when determining the best course of treatment 3.
Specific Considerations for Hemorrhagic Cysts
- Hemorrhagic cysts are a life-threatening complication of pancreatitis, requiring immediate treatment 4.
- The main symptom of hemorrhagic cysts is abdominal pain, and the most common etiology is acute pancreatitis 4.
- Surgical intervention, such as distal pancreatectomy or marsupialization, may be necessary to manage hemorrhagic cysts, with low complication and mortality rates 4.