How to manage a chronic alcoholic patient with epigastric pain, distension, and a history of severe epigastric pain radiating to the back, with a 4x5 cm retropancreatic collection on ultrasound (US), in the absence of fever or leucocytosis?

From the Guidelines

The management of this chronic alcoholic patient with a retropancreatic collection following severe epigastric pain two weeks ago would be percutaneous drainage (option C). This patient likely has a walled-off necrotic collection, which is a common complication of acute pancreatitis, especially in alcoholic patients. The 4x5 cm retropancreatic collection detected on ultrasound represents an encapsulated fluid collection that has persisted beyond the initial pancreatitis episode. Since the patient is symptomatic with epigastric pain and distension, intervention is warranted despite the absence of fever or leukocytosis (which suggests the collection is not infected) 1.

Key Considerations

• The patient's symptoms, such as epigastric pain and distension, indicate the need for intervention, as they are likely caused by the retropancreatic collection.
• The absence of fever or leukocytosis suggests that the collection is not infected, which is consistent with the patient's presentation.
• Percutaneous drainage is the preferred initial approach for symptomatic collections of this size as it is minimally invasive and effective, allowing for decompression of the collection, relief of symptoms, and analysis of the fluid 1.

Management Approach

• Percutaneous drainage involves CT or ultrasound-guided placement of a drainage catheter into the collection.
• If percutaneous drainage fails or if the collection recurs, internal drainage (endoscopic or surgical) might be considered as a second-line option.
• Antibiotics alone would be insufficient without drainage, as they would not address the underlying cause of the patient's symptoms.
• Reassurance is inappropriate for a symptomatic collection, as it would not provide relief for the patient's symptoms and could lead to further complications.

Rationale

• The 2019 WSES guidelines for the management of severe acute pancreatitis recommend a step-up approach starting with percutaneous or endoscopic drainage for symptomatic patients with walled-off necrotic collections or pseudocysts 1.
• The guidelines also note that interventions should be considered when organ dysfunctions persist for more than 4 weeks, and that a symptomatic disconnected pancreatic duct results in a peripancreatic collection and is an indication for interventions 1.

From the Research

Management of Pancreatic Pseudocysts and Necrosis

The patient presented with epigastric pain, distension, and a history of severe epigastric pain referred to the back, with a retropancreatic collection of 4x5 cm on ultrasound, but no fever or leucocytosis. The management of such cases can be considered based on the following options:

• Internal drainage: This approach is supported by studies such as 2, which discusses the treatment of pancreatic pseudocysts, pancreatic necrosis, and pancreatic duct leaks, including endoscopic treatment options.
• Percutaneous drainage: This method is also considered in the management of pancreatic pseudocysts and necrosis, as discussed in 3, which reviews current guidelines on the role of percutaneous catheter drainage and endoscopic techniques.
• Antibiotics: The use of antibiotics may be considered in cases with signs of infection, although the patient in question does not exhibit fever or leucocytosis.
• Reassure: Given the absence of fever or leucocytosis, a conservative approach might be initially considered, but the presence of a significant retropancreatic collection may require more active management.

Considerations for Management

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

• The size and location of the pancreatic pseudocyst or necrosis
• The presence of symptoms such as pain or obstruction
• The patient's overall health status and presence of any comorbidities
• The risk of complications, such as infection or bleeding

Evidence from Studies

Studies such as 4, 5, and 6 provide insights into the endoscopic management of pancreatic pseudocysts and necrosis, including the use of transmural endoscopic drainage, transpapillary drainage, and the placement of stents or nasocystic drainage tubes. These studies suggest that endoscopic management can be effective in treating these conditions, with high success rates and low complication rates in selected cases. However, the decision on the best management approach should be individualized based on the patient's specific circumstances and the expertise available.