Pseudocysts are like
cyst
A cyst is a closed sac, having a distinct envelope and cell division, division compared with the nearby Biological tissue, tissue. Hence, it is a cluster of Cell (biology), cells that have grouped together to form a sac (like the manner in which ...
s, but lack
epithelial
Epithelium or epithelial tissue is one of the four basic types of animal tissue, along with connective tissue, muscle tissue and nervous tissue. It is a thin, continuous, protective layer of compactly packed cells with a little intercellula ...
or
endothelial
The endothelium is a single layer of squamous endothelial cells that line the interior surface of blood vessels and lymphatic vessels. The endothelium forms an interface between circulating blood or lymph in the lumen and the rest of the vessel ...
cells. Initial management consists of general supportive care.
Symptom
Signs and symptoms are the observed or detectable signs, and experienced symptoms of an illness, injury, or condition. A sign for example may be a higher or lower temperature than normal, raised or lowered blood pressure or an abnormality showin ...
s and complications caused by pseudocysts require
surgery
Surgery ''cheirourgikē'' (composed of χείρ, "hand", and ἔργον, "work"), via la, chirurgiae, meaning "hand work". is a medical specialty that uses operative manual and instrumental techniques on a person to investigate or treat a pat ...
.
Computed tomography (CT) scans are used for initial imaging of cysts, and
endoscopic ultrasound
Endoscopic ultrasound (EUS) or echo-endoscopy is a medical procedure in which endoscopy (insertion of a probe into a hollow organ) is combined with ultrasound to obtain images of the internal organs in the chest, abdomen and colon. It can be used ...
s are used in differentiating between cysts and pseudocysts.
Endoscopic drainage
An endoscopy is a procedure used in medicine to look inside the body. The endoscopy procedure uses an endoscope to examine the interior of a hollow organ or cavity of the body. Unlike many other medical imaging techniques, endoscopes are insert ...
is a popular and effective method of treating pseudocysts.
This is not to be confused with the so-called "pseudocystic appearance", mainly
radiographically
Radiology ( ) is the medical discipline that uses medical imaging to diagnose diseases and guide their treatment, within the bodies of humans and other animals. It began with radiography (which is why its name has a root referring to radiatio ...
, of other lesions, such as
Stafne static bone cyst and
aneurysmal bone cyst
Aneurysmal bone cyst (ABC) is a non-cancerous bone tumor composed of multiple varying sizes of spaces in a bone which are filled with blood. The term is a misnomer, as the lesion is neither an aneurysm nor a cyst. It generally presents with pai ...
of the
jaw
The jaw is any opposable articulated structure at the entrance of the mouth, typically used for grasping and manipulating food. The term ''jaws'' is also broadly applied to the whole of the structures constituting the vault of the mouth and serv ...
s.
Signs and symptoms
Pseudocysts are often
asymptomatic
In medicine, any disease is classified asymptomatic if a patient tests as carrier for a disease or infection but experiences no symptoms. Whenever a medical condition fails to show noticeable symptoms after a diagnosis it might be considered asy ...
. Symptoms are more common in larger pseudocysts, though the size and time present usually are poor indicators of potential complications.
Pancreatic pseudocysts may cause
abdominal pain
Abdominal pain, also known as a stomach ache, is a symptom
Signs and symptoms are the observed or detectable signs, and experienced symptoms of an illness, injury, or condition. A sign for example may be a higher or lower temperature than ...
,
nausea
Nausea is a diffuse sensation of unease and discomfort, sometimes perceived as an urge to vomit. While not painful, it can be a debilitating symptom if prolonged and has been described as placing discomfort on the chest, abdomen, or back of the ...
and
vomiting
Vomiting (also known as emesis and throwing up) is the involuntary, forceful expulsion of the contents of one's stomach through the mouth and sometimes the Human nose, nose.
Vomiting can be the result of ailments like Food-poisoning, foo ...
, a bloated feeling, and trouble eating or digesting food. They also may become infected, rupture, or block part of the
intestine
The gastrointestinal tract (GI tract, digestive tract, alimentary canal) is the tract or passageway of the digestive system that leads from the mouth to the anus. The GI tract contains all the major organs of the digestive system, in humans ...
. Rarely, the infected pseudocyst causes
jaundice
Jaundice, also known as icterus, is a yellowish or greenish pigmentation of the skin and sclera due to high bilirubin levels. Jaundice in adults is typically a sign indicating the presence of underlying diseases involving abnormal heme meta ...
or
sepsis
Sepsis, formerly known as septicemia (septicaemia in British English) or blood poisoning, is a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs. This initial stage is follo ...
.
Mediastinal pseudocysts, a rare form of pancreatic pseudocysts in the abdomen, may cause
dysphagia
Dysphagia is difficulty in swallowing. Although classified under "symptoms and signs" in ICD-10, in some contexts it is classified as a disease#Terminology, condition in its own right.
It may be a sensation that suggests difficulty in the passag ...
,
dyspnea
Shortness of breath (SOB), also medically known as dyspnea (in AmE) or dyspnoea (in BrE), is an uncomfortable feeling of not being able to breathing, breathe well enough. The American Thoracic Society defines it as "a subjective experience of brea ...
, airway obstruction, or
cardiac tamponade
Cardiac tamponade, also known as pericardial tamponade (), is the buildup of fluid in the pericardium (the sac around the heart), resulting in compression of the heart. Onset may be rapid or gradual. Symptoms typically include those of obstruct ...
.
Adrenal pseudocysts may cause abdominal pain, along with various
gastrointestinal symptom
Gastrointestinal diseases (abbrev. GI diseases or GI illnesses) refer to diseases involving the gastrointestinal tract, namely the oesophagus, stomach, small intestine, large intestine and rectum, and the accessory organs of digestion, the live ...
s such as
nausea
Nausea is a diffuse sensation of unease and discomfort, sometimes perceived as an urge to vomit. While not painful, it can be a debilitating symptom if prolonged and has been described as placing discomfort on the chest, abdomen, or back of the ...
,
vomiting
Vomiting (also known as emesis and throwing up) is the involuntary, forceful expulsion of the contents of one's stomach through the mouth and sometimes the Human nose, nose.
Vomiting can be the result of ailments like Food-poisoning, foo ...
, and
constipation
Constipation is a bowel dysfunction that makes bowel movements infrequent or hard to pass. The stool is often hard and dry. Other symptoms may include abdominal pain, bloating, and feeling as if one has not completely passed the bowel movement ...
.
Cause
Pancreatic pseudocysts are often caused by acute or chronic
pancreatitis
Pancreatitis is a condition characterized by inflammation of the pancreas. The pancreas is a large organ behind the stomach that produces digestive enzymes and a number of hormones. There are two main types: acute pancreatitis, and chronic pancr ...
.
They may also be caused by
trauma
Trauma most often refers to:
* Major trauma, in physical medicine, severe physical injury caused by an external source
* Psychological trauma, a type of damage to the psyche that occurs as a result of a severely distressing event
*Traumatic i ...
to the abdomen, with a higher frequency in children.
Pseudocysts are more often present in chronic pancreatitis patients than acute pancreatitis patients. Also, if the pancreatitis is alcohol induced, there is a higher incidence of pseudocysts. These alcohol-related pseudocysts account for 59%-78% of all pancreatic pseudocysts. Actual pancreatic pseudocyst incidence is small, at around 1.6%-4.5%, or .5-1 per 100,000 adults per year.
Types of adrenal cysts include parasitic cysts, epithelial cysts, endothelial cysts, and pseudocysts. 56% of all adrenal cyst-like changes are pseudocysts, and only 7% of those pseudocysts are malignant or potentially
malignant
Malignancy () is the tendency of a medical condition to become progressively worse.
Malignancy is most familiar as a characterization of cancer. A ''malignant'' tumor contrasts with a non-cancerous ''benign'' tumor in that a malignancy is not s ...
.
The cause of adrenal pseudocysts is unknown. A few theories exist, but it is believed that repeated episodes of trauma, infection, or bleeding may cause collagen formation leading to the formation of a fibrous lining.
Retinal pseudocysts may be related to
geographic atrophy. A study found that 22% of eyes with geographic atrophy contained pseudocysts.
In American trypanosomiasis (
Chagas’ disease), the
parasite
Parasitism is a close relationship between species, where one organism, the parasite, lives on or inside another organism, the host, causing it some harm, and is adapted structurally to this way of life. The entomologist E. O. Wilson has ...
''
Trypanosoma cruzi
''Trypanosoma cruzi'' is a species of parasitic euglenoids. Among the protozoa, the trypanosomes characteristically bore tissue in another organism and feed on blood (primarily) and also lymph. This behaviour causes disease or the likelihood of ...
'' forms pseudocysts, particularly within muscular and neurological tissue.
Within these pseudocysts the parasites enter their
amastigote
An amastigote is a protist
A protist () is any eukaryotic organism (that is, an organism whose cells contain a cell nucleus) that is not an animal, plant, or fungus. While it is likely that protists share a common ancestor (the last eukaryot ...
stage, reproducing
asexually, before rupturing from the pseudocyst and entering the bloodstream.
Diagnosis
Description
A pseudocyst is a cystic lesion that may appear as a cyst on scans, but lacks epithelial or endothelial cells.
An acute pancreatic pseudocyst is made of
pancreatic fluids with a wall of
fibrous
Fiber or fibre (from la, fibra, links=no) is a #Natural fibers, natural or Fiber#Artificial fibers, artificial substance that is significantly longer than it is wide. Fibers are often used in the manufacture of other materials. The stronge ...
tissue or
granulation
Granulation is the process of forming grains or granules from a powdery or solid substance, producing a granular material. It is applied in several technological processes in the chemical and pharmaceutical industries. Typically, granulation invo ...
. Pseudocysts may form in a number of places, including the
pancreas
The pancreas is an organ of the digestive system and endocrine system of vertebrates. In humans, it is located in the abdomen behind the stomach and functions as a gland. The pancreas is a mixed or heterocrine gland, i.e. it has both an end ...
,
abdomen
The abdomen (colloquially called the belly, tummy, midriff, tucky or stomach) is the part of the body between the thorax (chest) and pelvis, in humans and in other vertebrates. The abdomen is the front part of the abdominal segment of the torso. ...
,
adrenal gland
The adrenal glands (also known as suprarenal glands) are endocrine glands that produce a variety of hormones including adrenaline and the steroids aldosterone and cortisol. They are found above the kidneys. Each gland has an outer cortex which ...
, and
eye.
Pancreatic pseudocysts
The most common and effective method of diagnosing a pancreatic pseudocyst is with a
CT scan. A pseudocyst generally appears as a fluid-filled mass. In some instances, other methods must be used to distinguish between a normal cyst and a pseudocyst.
This is usually accomplished with
endoscopic ultrasound
Endoscopic ultrasound (EUS) or echo-endoscopy is a medical procedure in which endoscopy (insertion of a probe into a hollow organ) is combined with ultrasound to obtain images of the internal organs in the chest, abdomen and colon. It can be used ...
or with
fine needle aspiration
Fine-needle aspiration (FNA) is a diagnostic procedure used to investigate lumps or masses. In this technique, a thin (23–25 gauge (0.52 to 0.64 mm outer diameter)), hollow needle is inserted into the mass for sampling of cells that, aft ...
.
Transabdominal ultrasound can be used to identify pseudocysts, which appear on the scan as echoic structures associated with
distal acoustic enhancement. They tend to be round and enclosed in a smooth wall. Pseudocysts may appear more complex when young, hemorrhaged, or when complicated due to infection. The transabdominal ultrasound has a sensitivity rate in detection of pancreatic pseusocysts of 75%-90%, making it inferior to a CT scan, which has a rate of 90%-100%.
CT scans are more accurate, and provide more detail regarding the pseudocyst and its surroundings. The CT scan's weakness is its lack of differentiation between pseudocysts and
cystic neoplasm. Also, the
intravenous
Intravenous therapy (abbreviated as IV therapy) is a medical technique that administers fluids, medications and nutrients directly into a person's vein. The intravenous route of administration is commonly used for rehydration or to provide nutrie ...
contrast given at the time of the CT scan may worsen kidney dysfunction.
MRI
Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to form pictures of the anatomy and the physiological processes of the body. MRI scanners use strong magnetic fields, magnetic field gradients, and radio waves ...
and
MRCP are effective methods of detecting pseudocysts, but are not regularly used because CT scans offer most of the needed information. These scans do, however, provide better contrast, which allows for better characterization of fluid collections, depicting debris within the collections, and detection of bleeding.
Endoscopic ultrasound
Endoscopic ultrasound (EUS) or echo-endoscopy is a medical procedure in which endoscopy (insertion of a probe into a hollow organ) is combined with ultrasound to obtain images of the internal organs in the chest, abdomen and colon. It can be used ...
is generally used as a secondary test to further evaluate the cysts found in other tests, and is used when determining if a cyst is a pseudocyst or not.
Adrenal pseudocysts
Adrenal pseudocysts are found in much the same way as pancreatic pseudocysts, with CT scans. In addition,
adrenalectomies are used to diagnose the lesion and sometimes relieve pain.
Prevention
Because pseudocysts are closely related to other conditions, such as
pancreatitis
Pancreatitis is a condition characterized by inflammation of the pancreas. The pancreas is a large organ behind the stomach that produces digestive enzymes and a number of hormones. There are two main types: acute pancreatitis, and chronic pancr ...
and alcohol use, the prevention of pseudocysts lies in the prevention of the main problem.
Treatment
Not all cysts require treatment. Many pancreatic pseudocysts improve and disappear by themselves. If the cysts are small and are not causing symptoms, careful observation with periodic CT scans is often done. Pseudocysts that persist over many months or that cause symptoms require treatment.
Supportive medical care used to help small pseudocysts go away includes the use of
intravenous
Intravenous therapy (abbreviated as IV therapy) is a medical technique that administers fluids, medications and nutrients directly into a person's vein. The intravenous route of administration is commonly used for rehydration or to provide nutrie ...
fluids,
analgesics
An analgesic drug, also called simply an analgesic (American English), analgaesic (British English), pain reliever, or painkiller, is any member of the group of drugs used to achieve relief from pain (that is, analgesia or pain management). It i ...
, and
antiemetics
An antiemetic is a drug that is effective against vomiting and nausea. Antiemetics are typically used to treat motion sickness and the side effects of opioid analgesics, general anaesthetics, and chemotherapy directed against cancer. They may be ...
. Doctors often recommend a
low-fat diet
A low-fat diet is one that restricts fat, and often saturated fat and cholesterol as well. Low-fat diets are intended to reduce the occurrence of conditions such as heart disease and obesity. For weight loss, they perform similarly to a low-carb ...
for those who can tolerate oral intake.
Surgery
Surgery ''cheirourgikē'' (composed of χείρ, "hand", and ἔργον, "work"), via la, chirurgiae, meaning "hand work". is a medical specialty that uses operative manual and instrumental techniques on a person to investigate or treat a pat ...
is usually required in the treatment of pseudocysts with
symptoms
Signs and symptoms are the observed or detectable signs, and experienced symptoms of an disease, illness, injury, or condition. A sign for example may be a higher or lower temperature than normal, raised or lowered blood pressure or an abnormali ...
or
complications. There are three main methods for draining a pancreatic pseudocyst:
endoscopic drainage
An endoscopy is a procedure used in medicine to look inside the body. The endoscopy procedure uses an endoscope to examine the interior of a hollow organ or cavity of the body. Unlike many other medical imaging techniques, endoscopes are insert ...
,
percutaneous {{More citations needed, date=January 2021
In surgery, a percutaneous procedurei.e. Granger et al., 2012 is any medical procedure or method where access to inner organs or other tissue is done via needle-puncture of the skin, rather than by using ...
catheter
In medicine, a catheter (/ˈkæθətər/) is a thin tube made from medical grade materials serving a broad range of functions. Catheters are medical devices that can be inserted in the body to treat diseases or perform a surgical procedure. Cath ...
drainage, or
open surgery
Minimally invasive procedures (also known as minimally invasive surgeries) encompass surgical techniques that limit the size of incisions needed, thereby reducing wound healing time, associated pain, and risk of infection. Surgery by definiti ...
. Endoscopic drainage tends to be the preferred method due to it being less invasive and having a high long-term success rate.
Percutaneous drainage involves the guidance of a
CT scan or
ultrasound
Ultrasound is sound waves with frequency, frequencies higher than the upper audible limit of human hearing range, hearing. Ultrasound is not different from "normal" (audible) sound in its physical properties, except that humans cannot hea ...
. A drainage
catheter
In medicine, a catheter (/ˈkæθətər/) is a thin tube made from medical grade materials serving a broad range of functions. Catheters are medical devices that can be inserted in the body to treat diseases or perform a surgical procedure. Cath ...
is placed into the fluid cavity to drain the fluid, which is then collected over several weeks into an external collection system. The catheter is removed when the drainage becomes minimal. Once the catheter is removed, contrast is injected into the cyst cavity to determine the remaining size and to monitor progress. The success rate is around 50%, and the unsuccessful drainages are mostly caused by large ductal leaks or blockage of the main
pancreatic duct
The pancreatic duct, or duct of Wirsung (also, the major pancreatic duct due to the existence of an accessory pancreatic duct), is a duct joining the pancreas to the common bile duct. This supplies it with pancreatic juice from the exocrine pancre ...
. This method is not recommended when patients cannot manage a catheter at home or with patients whose cysts contain bloody or solid material.
Surgical drainage of a pseudocyst involves creating a pathway between the pseudocyst cavity and the stomach or small bowel. This method is generally only used if the patient cannot tolerate or failed percutaneous or endoscopic drainage. This method is more risky than the others.
Endoscopic drainage is becoming the preferred method of draining pseudocysts because it is less invasive, does not require external drain, and has a large long-term success rate. Drainage is usually achieved with a
transpapillary approach with
ERCP
Endoscopic retrograde cholangiopancreatography (ERCP) is a technique that combines the use of endoscopy and fluoroscopy to diagnose and treat certain problems of the biliary or pancreatic ductal systems. It is primarily performed by highly skille ...
. Sometimes a direct drainage across the
stomach
The stomach is a muscular, hollow organ in the gastrointestinal tract of humans and many other animals, including several invertebrates. The stomach has a dilated structure and functions as a vital organ in the digestive system. The stomach i ...
or
duodenal
The duodenum is the first section of the small intestine in most higher vertebrates, including mammals, reptiles, and birds. In fish, the divisions of the small intestine are not as clear, and the terms anterior intestine or proximal intestine ...
wall is used instead. The transpapillary approach is used when the pseudocyst is in communication with the main pancreatic duct, and is also successful in patients with pancreatic duct disruption. Transgastric or transduodenal approaches are used when the pseudocyst is next to the gastro-duodenal wall. Endoscopic ultrasound is the most commonly used test to gather the needed information about the pseudocyst for this method.
The endoscopic method depends on the presence of a bulge into the stomach or duodenum to determine the site for
catheterization. Inherent risks include missing the pseudocyst, injuring nearby vessels, and inefficient placement of the catheter. In patients with chronic pseudocysts, this approach has a 90% success rate. Recurrence after drainage is around 4%, and the complication rate is below 16%.
To treat adrenal pseudocysts, an adrenalectomy or laproscopy may be used.
References
External links
{{Tumors
Gross pathology