What is the treatment for pancreatic pseudocyst or abscess?

Treatment of Pancreatic Pseudocysts and Abscesses

Endoscopic drainage is the preferred first-line treatment for symptomatic pancreatic pseudocysts, while infected collections (abscesses) require immediate drainage, with endoscopic approaches offering better outcomes than surgical intervention. 1

Classification and Diagnosis

Proper classification is essential for management:

• Pancreatic pseudocyst: An encapsulated fluid collection with a well-defined inflammatory wall with minimal or no necrosis that develops after 4 weeks from onset of pancreatitis 1, 2
• Pancreatic abscess: Any subtype of pancreatic collection that becomes infected, associated with high mortality rates 1

Diagnostic modalities:

• CT scan is the primary diagnostic tool for confirming pseudocysts and abscesses 1
• MRI/MRCP can assess communication with pancreatic duct 1
• Endoscopic ultrasound (EUS) helps distinguish pseudocysts from other cystic lesions 1

Treatment Algorithm

1. Conservative Management

• Appropriate for:
  • Small (<5 cm), stable, asymptomatic pseudocysts 1
  • Many pseudocysts resolve spontaneously without intervention 1

2. Indications for Drainage

Intervention is required for:

• Symptomatic pseudocysts (pain, early satiety)
• Enlarging collections
• Infected collections (abscesses)
• Collections causing obstruction (biliary, gastric outlet)
• Suspicion of malignancy 1, 3

3. Drainage Options

A. Endoscopic Drainage

• First-line approach for mature, symptomatic pseudocysts 1
• Advantages:
  • Shorter hospital stays
  • Better patient-reported outcomes compared to surgery 1
  • Success rates of 94% for pseudocysts (vs 80% for abscesses) 4
  • Lower complication rates for pseudocysts (6%) than abscesses (30%) 4
• Best for:
  • Central collections
  • Collections adjacent to stomach or duodenum 1

B. Percutaneous Catheter Drainage (PCD)

• Indicated for:
  • Infected collections (abscesses) 1
  • Patients who are poor surgical candidates 1
  • Collections in the tail of pancreas 1
  • Collections not communicating with pancreatic duct 1
• Limitations:
  • Higher rates of reintervention
  • Longer hospital stays
  • More follow-up imaging studies compared to endoscopic approaches 1
  • Cure rates of only 14-32% when used as primary therapy 1

C. Surgical Drainage

• Reserved for:
  • Failed endoscopic or percutaneous drainage 1
  • Multiple or giant pseudocysts
  • Suspected malignancy
  • Complications related to chronic pancreatitis 3
• Options include:
  • Cyst-gastrostomy
  • Roux-en-Y pseudocyst-jejunostomy (for infracolic extension) 1
• Lower recurrence rates (2.5-5%) compared to endoscopic drainage 1

Special Considerations

Infected Collections (Abscesses)

• Require urgent drainage due to high mortality risk 1
• Endoscopic drainage has better outcomes but higher complication rates than for pseudocysts 4
• PCD may be used as a temporizing measure before definitive treatment 1

Complications to Monitor

• Bleeding (occurs in up to 14% of endoscopic procedures) 1
• Perforation requiring laparotomy 1
• Recurrence (more common with endoscopic treatment) 1
• Infection of previously sterile collections 5

Follow-up

• CT or MRI imaging to confirm resolution
• Ultrasound can be used for follow-up of fluid collections to reduce radiation exposure 1
• ERCP may be needed for persistent pancreatic fistulas or main duct strictures 1

Pitfalls to Avoid

1. Premature intervention: Wait at least 4 weeks from onset of pancreatitis for pseudocyst wall maturation 1, 2
2. Misdiagnosis: Up to 20% of presumed pseudocysts may be cystic neoplasms; confirm diagnosis before drainage 3
3. Inappropriate drainage technique: Consider collection location, communication with pancreatic duct, and presence of infection when selecting approach 3
4. Delayed treatment of infected collections: Infected collections require prompt drainage to prevent sepsis and mortality 1