Walled-off pancreatic fluid collections (including pseudocysts)
- Douglas A Howell, MD, FASGE, FACG
Douglas A Howell, MD, FASGE, FACG
- Section Editor — EUS/ERCP
- Assistant Clinical Professor of Medicine, Tufts Medical School Director,
- Pancreaticobiliary Center Director, Advanced Interventional Endoscopy Fellowship, Maine Medical Center
- Raj J Shah, MD, FASGE, AGAF
Raj J Shah, MD, FASGE, AGAF
- Professor of Medicine, University of Colorado School of Medicine
- Director, Pancreaticobiliary Endoscopy
- Digestive Health Center, University of Colorado Hospital, Anschutz Medical Campus
Walled-off pancreatic fluid collections are often the result of acute pancreatitis. They may also be seen in patients with chronic pancreatitis and in patients who have suffered blunt or penetrating pancreatic trauma.
●Walled-off pancreatic fluid collections occur after an acute attack of pancreatitis in approximately 10 percent of cases [1,2]. Necrosis of peripancreatic tissue can progress to liquefaction with subsequent organization and eventual evolution into a walled-off fluid collection that may communicate with the pancreatic duct. Alternatively, a walled-off fluid collection may result from parenchymal necrosis, which can lead to complete ductal disruption and gross leakage of pancreatic fluid.
●Among patients with chronic pancreatitis, a walled-off pancreatic fluid collection can be induced by an acute exacerbation of pancreatitis or by progressive ductal obstruction. The ensuing elevation in intraductal pressure may then induce ductal leakage, with accumulation of a peripancreatic fluid collection. (See "Overview of the complications of chronic pancreatitis".)
●Blunt or penetrating trauma (including iatrogenic injury, such as pancreatic surgery) can directly disrupt the pancreatic duct, leading to formation of a walled-off fluid collection.
In the past, many of these fluid collections were referred to as pseudocysts. However, in 2013, the terminology used to describe pancreatic fluid collections developing in the setting of acute pancreatitis was updated, and the majority of walled-off pancreatic fluid collections now fall into the category of walled-off pancreatic necrosis. (See 'Diagnosis' below.)
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- CLINICAL MANIFESTATIONS
- Fluid sampling
- DIFFERENTIAL DIAGNOSIS
- Expectant management
- Drainage options
- - Surgical drainage
- - Endoscopic drainage
- Complex fluid collections and pancreatic necrosis
- Immature wall
- - Percutaneous catheter drainage
- SUMMARY AND RECOMMENDATIONS