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Walled-off pancreatic fluid collections (including pseudocysts)

Douglas A Howell, MD, FASGE, FACG
Section Editor
David C Whitcomb, MD, PhD
Deputy Editor
Anne C Travis, MD, MSc, FACG, AGAF


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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Literature review current through: Sep 2016. | This topic last updated: Dec 9, 2014.
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  1. Cameron JL. Acute pancreatitis. In: Surgery of the Alimentary Tract, 2nd edition, Shackelford RT, Zuideme GD (Eds), WB Saunders, Philadelphia 1983. p.31.
  2. O'Malley VP, Cannon JP, Postier RG. Pancreatic pseudocysts: cause, therapy, and results. Am J Surg 1985; 150:680.
  3. Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013; 62:102.
  4. Acevedo-Piedra NG, Moya-Hoyo N, Rey-Riveiro M, et al. Validation of the determinant-based classification and revision of the Atlanta classification systems for acute pancreatitis. Clin Gastroenterol Hepatol 2014; 12:311.
  5. Cheruvu CV, Clarke MG, Prentice M, Eyre-Brook IA. Conservative treatment as an option in the management of pancreatic pseudocyst. Ann R Coll Surg Engl 2003; 85:313.
  6. Risti B, Marincek B, Jost R, et al. Hemosuccus pancreaticus as a source of obscure upper gastrointestinal bleeding: three cases and literature review. Am J Gastroenterol 1995; 90:1878.
  7. Runyon BA. Amylase levels in ascitic fluid. J Clin Gastroenterol 1987; 9:172.
  8. Sperti C, Cappellazzo F, Pasquali C, et al. Cystic neoplasms of the pancreas: problems in differential diagnosis. Am Surg 1993; 59:740.
  9. Warshaw AL, Rutledge PL. Cystic tumors mistaken for pancreatic pseudocysts. Ann Surg 1987; 205:393.
  10. Lewandrowski KB, Southern JF, Pins MR, et al. Cyst fluid analysis in the differential diagnosis of pancreatic cysts. A comparison of pseudocysts, serous cystadenomas, mucinous cystic neoplasms, and mucinous cystadenocarcinoma. Ann Surg 1993; 217:41.
  11. Levin MF, Vellet AD, Bach DB, et al. Peripancreatic fluid collections: vascular structures masquerading as pseudocysts. Can Assoc Radiol J 1992; 43:267.
  12. Gluck M, Ross A, Irani S, et al. Dual modality drainage for symptomatic walled-off pancreatic necrosis reduces length of hospitalization, radiological procedures, and number of endoscopies compared to standard percutaneous drainage. J Gastrointest Surg 2012; 16:248.
  13. Vitas GJ, Sarr MG. Selected management of pancreatic pseudocysts: operative versus expectant management. Surgery 1992; 111:123.
  14. Yeo CJ, Bastidas JA, Lynch-Nyhan A, et al. The natural history of pancreatic pseudocysts documented by computed tomography. Surg Gynecol Obstet 1990; 170:411.
  15. Yasuda I, Nakashima M, Iwai T, et al. Japanese multicenter experience of endoscopic necrosectomy for infected walled-off pancreatic necrosis: The JENIPaN study. Endoscopy 2013; 45:627.
  16. Köhler H, Schafmayer A, Lüdtke FE, et al. Surgical treatment of pancreatic pseudocysts. Br J Surg 1987; 74:813.
  17. Gumaste VV, Pitchumoni CS. Pancreatic pseudocyst. Gastroenterologist 1996; 4:33.
  18. Bergman S, Melvin WS. Operative and nonoperative management of pancreatic pseudocysts. Surg Clin North Am 2007; 87:1447.
  19. Frantzides CT, Ludwig KA, Redlich PN. Laparoscopic management of a pancreatic pseudocyst. J Laparoendosc Surg 1994; 4:55.
  20. Park AE, Heniford BT. Therapeutic laparoscopy of the pancreas. Ann Surg 2002; 236:149.
  21. Dávila-Cervantes A, Gómez F, Chan C, et al. Laparoscopic drainage of pancreatic pseudocysts. Surg Endosc 2004; 18:1420.
  22. Park A, Schwartz R, Tandan V, Anvari M. Laparoscopic pancreatic surgery. Am J Surg 1999; 177:158.
  23. Barragan B, Love L, Wachtel M, et al. A comparison of anterior and posterior approaches for the surgical treatment of pancreatic pseudocyst using laparoscopic cystogastrostomy. J Laparoendosc Adv Surg Tech A 2005; 15:596.
  24. Rattner DW, Fernandez-del Castillo C, Warshaw AL. Pitfalls of distal pancreatectomy for relief of pain in chronic pancreatitis. Am J Surg 1996; 171:142.
  25. Howard TJ, Rhodes GJ, Selzer DJ, et al. Roux-en-Y internal drainage is the best surgical option to treat patients with disconnected duct syndrome after severe acute pancreatitis. Surgery 2001; 130:714.
  26. Lawrence C, Howell DA, Stefan AM, et al. Disconnected pancreatic tail syndrome: potential for endoscopic therapy and results of long-term follow-up. Gastrointest Endosc 2008; 67:673.
  27. Pelaez-Luna M, Vege SS, Petersen BT, et al. Disconnected pancreatic duct syndrome in severe acute pancreatitis: clinical and imaging characteristics and outcomes in a cohort of 31 cases. Gastrointest Endosc 2008; 68:91.
  28. Morgan DE, Baron TH, Smith JK, et al. Pancreatic fluid collections prior to intervention: evaluation with MR imaging compared with CT and US. Radiology 1997; 203:773.
  29. Hariri M, Slivka A, Carr-Locke DL, Banks PA. Pseudocyst drainage predisposes to infection when pancreatic necrosis is unrecognized. Am J Gastroenterol 1994; 89:1781.
  30. Hookey LC, Debroux S, Delhaye M, et al. Endoscopic drainage of pancreatic-fluid collections in 116 patients: a comparison of etiologies, drainage techniques, and outcomes. Gastrointest Endosc 2006; 63:635.
  31. Baron TH, Harewood GC, Morgan DE, Yates MR. Outcome differences after endoscopic drainage of pancreatic necrosis, acute pancreatic pseudocysts, and chronic pancreatic pseudocysts. Gastrointest Endosc 2002; 56:7.
  32. Seewald S, Groth S, Omar S, et al. Aggressive endoscopic therapy for pancreatic necrosis and pancreatic abscess: a new safe and effective treatment algorithm (videos). Gastrointest Endosc 2005; 62:92.
  33. Papachristou GI, Takahashi N, Chahal P, et al. Peroral endoscopic drainage/debridement of walled-off pancreatic necrosis. Ann Surg 2007; 245:943.
  34. Gardner TB, Coelho-Prabhu N, Gordon SR, et al. Direct endoscopic necrosectomy for the treatment of walled-off pancreatic necrosis: results from a multicenter U.S. series. Gastrointest Endosc 2011; 73:718.
  35. El Hamel A, Parc R, Adda G, et al. Bleeding pseudocysts and pseudoaneurysms in chronic pancreatitis. Br J Surg 1991; 78:1059.
  36. Kiviluoto T, Schröder T, Kivilaakso E, Lempinen M. Acute haemorrhage associated with pancreatic pseudocyst and chronic pancreatitis. Ann Chir Gynaecol 1984; 73:214.
  37. Pitkäranta P, Haapiainen R, Kivisaari L, Schröder T. Diagnostic evaluation and aggressive surgical approach in bleeding pseudoaneurysms associated with pancreatic pseudocysts. Scand J Gastroenterol 1991; 26:58.
  38. Arvanitakis M, Delhaye M, De Maertelaere V, et al. Computed tomography and magnetic resonance imaging in the assessment of acute pancreatitis. Gastroenterology 2004; 126:715.
  39. Barge JU, Lopera JE. Vascular complications of pancreatitis: role of interventional therapy. Korean J Radiol 2012; 13 Suppl 1:S45.
  40. Marshall GT, Howell DA, Hansen BL, et al. Multidisciplinary approach to pseudoaneurysms complicating pancreatic pseudocysts. Impact of pretreatment diagnosis. Arch Surg 1996; 131:278.
  41. Elton E, Howell DA, Amberson SM, Dykes TA. Combined angiographic and endoscopic management of bleeding pancreatic pseudoaneurysms. Gastrointest Endosc 1997; 46:544.
  42. Adams DB, Anderson MC. Percutaneous catheter drainage compared with internal drainage in the management of pancreatic pseudocyst. Ann Surg 1992; 215:571.
  43. Szentes MJ, Traverso LW, Kozarek RA, Freeny PC. Invasive treatment of pancreatic fluid collections with surgical and nonsurgical methods. Am J Surg 1991; 161:600.
  44. vanSonnenberg E, Wittich GR, Casola G, et al. Complicated pancreatic inflammatory disease: diagnostic and therapeutic role of interventional radiology. Radiology 1985; 155:335.
  45. Mueller PR. Percutaneous drainage of pancreatic necrosis: is it ecstasy or agony? AJR Am J Roentgenol 1998; 170:976.
  46. Traverso LW, Kozarek RA. Pancreatic necrosectomy: definitions and technique. J Gastrointest Surg 2005; 9:436.
  47. Balthazar EJ. Acute pancreatitis: assessment of severity with clinical and CT evaluation. Radiology 2002; 223:603.
  48. Baril NB, Ralls PW, Wren SM, et al. Does an infected peripancreatic fluid collection or abscess mandate operation? Ann Surg 2000; 231:361.
  49. Ocampo C, Oría A, Zandalazini H, et al. Treatment of acute pancreatic pseudocysts after severe acute pancreatitis. J Gastrointest Surg 2007; 11:357.
  50. Freeny PC, Hauptmann E, Althaus SJ, et al. Percutaneous CT-guided catheter drainage of infected acute necrotizing pancreatitis: techniques and results. AJR Am J Roentgenol 1998; 170:969.
  51. Mortelé KJ, Girshman J, Szejnfeld D, et al. CT-guided percutaneous catheter drainage of acute necrotizing pancreatitis: clinical experience and observations in patients with sterile and infected necrosis. AJR Am J Roentgenol 2009; 192:110.
  52. Besselink MG, van Santvoort HC, Nieuwenhuijs VB, et al. Minimally invasive 'step-up approach' versus maximal necrosectomy in patients with acute necrotising pancreatitis (PANTER trial): design and rationale of a randomised controlled multicenter trial [ISRCTN13975868]. BMC Surg 2006; 6:6.
  53. van Santvoort HC, Besselink MG, Bakker OJ, et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med 2010; 362:1491.
  54. Nealon WH, Walser E. Main pancreatic ductal anatomy can direct choice of modality for treating pancreatic pseudocysts (surgery versus percutaneous drainage). Ann Surg 2002; 235:751.