What to report in a pancreatic pseuocyst or a walled of necrotic collection (WON)
Nomenclature is based on type of pancreatitis and time line
Timeline: < 4 weeks
1. IEP: Interstitial edematous pancreatitis: Acute pancreatic fluid collections
2. Necrotizing pancreatitis: Acute necrotic collection
Timeline: > 4 weeks
1. IEP- Interstitial edematous pancreatitis: Pseudocyst
2. Necrotizing pancreatitis: Walled off necrotic collection
What to report
1. Size
2. Contents - fluid / debris / hemorrhage /
3. Wall - is it is well formed
4. Communication with the pancreatic duct
5. If ruptured - extent of spread
6. Any vascular complication - arterial aneurysm / venous thrombosis and collateral formation
Fig 2 a. Walled of necrotic collection with fat necrosis. fig. 2 b: The patient presented with pain and on CT Scan, the necrotic collection is reduced i size with loss of wall definition and new acute collection in the transverse mesocolon (red star)
Management:
1. Conservative (# masterly Inactivity):
You don't have to actively intervene, human body is amazing and takes care on its own. See Fig. 3 below:
Fig 3 a. Walled of necrotic collection with debris on MRI image. fig. 3 b: Follow up CECT after months shows resolution of the collection.
2. Active intervene (either surgery or interventional radiology procedure):
1. Infected (image guided drainage or necrosectomy)
2. Aneurysm formation ( embolization)
3. Rupture - observe vs intervene (image guided driange)
4. Communication with pancreatic duct - observe vs intervene (if keeps on increasing and is at risk of rupture) - Stenting by ERCP
5. Pressure effects: Cysto gastrostomy or image guided drainage
6. Portal hypertension due to PV thrombosis: Variceal banding if bleeding happens. Surgical shunt or TIPPS for off loading the pressure.
Prepared by Dr. Sharad Maheshwari
11.11.2022
Update: 14.11.2022
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