NMS. Casos Clínicos

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Part II ♦ Specific Disorders

Figure 7-24: CT scan of the abdomen showing a pancreatic pseudocyst ( arrows ).

Q: What is the next step? A: Treatment involves beginning feeding and following the patient’s symptoms and serum am- ylase. If these are stable, then the pseudocyst is resolving , and the patient feels better and can be discharged.

Q: How would you manage the patient if the pain and other symptoms continued or recurred and the serum amylase remained elevated? A: The 6-week waiting period is observed for two reasons: Many pseudocysts resolve within 6 weeks; if not, the cyst wall must contain enough fibrous tissue to allow surgical suturing to occur. There are many ways to treat pancreatic pseudocysts. The best way has not been precisely determined, and each approach has its own advantages and disadvantages. One approach is percutaneous drainage by radiologic guidance, which is technically easy to do but has a high recurrence rate and may lead to infection of the pseudocyst and the develop- ment of a pancreaticocutaneous fistula. If a pseudocyst is present on CT and the patient fails to improve by 6 weeks, intervention is appropriate. Stenting the pancreatic duct with ERCP past the ductal injury can be done. Many feel the procedure of choice involves internal drainage of the fluid collection into the GI tract. Internal drainage of a pancreatic pseudocyst can be performed endoscopically or surgically. Endoscopic drainage is performed through an endoscope using EUS guidance (Fig. 7-25). A stent or stents are placed from the duodenal or gastric lumen through the enteric wall and pseudocyst wall into the pseudocyst itself allowing pseudocyst contents to drain into the stomach. This approach is less invasive than a surgical approach but is less likely to be successful if the pseudocyst has a large amount of debris and complex fluid. Surgically, the most common procedure is a cystogastrostomy (Fig. 7-26). The surgeon opens the stomach anteriorly and locates the cyst with a needle and syringe through the posterior stomach. Because the cyst is contiguous with the posterior stomach wall in most cases, it is possible to make a communication with the cyst through the posterior wall. This SAMPLE