What is the diagnosis and treatment for a peritoneal pseudocyst?

From the Guidelines

The diagnosis and treatment of a peritoneal pseudocyst should involve EUS-guided drainage as the optimal approach for uncomplicated pseudocysts located adjacent to the stomach or duodenum. This approach is supported by the Asian EUS Group RAND/UCLA expert panel, which concluded that EUS-guided drainage is the optimal drainage approach in uncomplicated pseudocysts 1.

Diagnosis and Treatment Considerations

When managing peritoneal pseudocysts, it's essential to consider the size, symptoms, and underlying cause of the pseudocyst. For symptomatic pseudocysts, drainage is often necessary to alleviate symptoms and prevent complications. The choice of drainage method depends on the location and complexity of the pseudocyst.

Drainage Methods

• EUS-guided drainage is a minimally invasive approach that involves using endoscopic ultrasonography to guide the placement of a drainage catheter into the pseudocyst 1.
• Percutaneous drainage involves inserting a catheter under ultrasound or CT guidance to drain the fluid 1.
• Surgical intervention, including laparoscopic or open excision of the cyst wall, may be necessary for recurrent or complex pseudocysts 1.

Follow-up and Monitoring

Patients with peritoneal pseudocysts typically require follow-up imaging at 3-6 month intervals to assess for recurrence. The formation of these pseudocysts relates to inflammatory processes that trigger fibrin deposition, leading to a non-epithelialized cavity filled with serous fluid 1. Unlike true cysts, pseudocysts lack an epithelial lining, which influences their management approach and recurrence potential.

Key Considerations

• The Asian EUS Group RAND/UCLA expert panel concluded that EUS-guided drainage is the optimal drainage approach in uncomplicated pseudocysts, with a high evidence level 1.
• Surgical drainage has been shown to have no significant morbidity associated with it and no deaths, with no pseudocysts recurring after surgical drainage 1.

From the Research

Diagnosis of Peritoneal Pseudocyst

• The diagnosis of a peritoneal pseudocyst is based on the presence of symptoms, enlargement of the cyst, complications (infection, hemorrhage, rupture, and obstruction), and suspicion of malignancy 2
• Imaging studies are used to confirm the diagnosis and to evaluate the size, number, and location of the cysts 2

Treatment of Peritoneal Pseudocyst

• The available forms of therapy include percutaneous drainage, transendoscopic approach, and surgery 2
• The choice of procedure depends on a number of factors, including the general condition of the patient, size, number, and location of cysts, presence or absence of communication of the cyst with the pancreatic duct, presence or absence of infection, and suspicion of malignancy 2
• Percutaneous catheter drainage is safe and effective and should be the treatment of first choice in poor-risk patients, for immature cysts, and for infected pseudocysts 2
• Endoscopic drainage is less invasive, less expensive, and easier to perform with better outcomes in smaller pseudocysts and pancreatic head pseudocysts, but expertise is limited 2
• Surgical treatment is still the preferred treatment in most centers, especially for multiple pseudocysts, giant pseudocysts, presence of other complications related to chronic pancreatitis, and suspected malignancy 2

Endoscopic Ultrasound-Guided Drainage

• Endoscopic ultrasound-guided pancreatic pseudocyst drainage (EUS-PPD) is a promising treatment for pancreatic pseudocysts 3
• EUS-PPD has a high success rate, with placement of a naso-cystic drainage successful in 92% of patients 3
• However, the insertion of the tube is difficult in cases with a thickened cystic wall, and infected pseudocysts are often difficult to treat by only short-term external drainage 3

Resolution and Recurrence

• Resolution rates after surgical and non-surgical methods are comparable 4
• Recurrence of the pseudocyst can occur, and additional treatments may be necessary 3
• The choice of treatment should be individualized, taking into account the patient's condition, the size and location of the cyst, and the presence of complications 4, 5, 6