An Evaluation of Pancreatic Pseudocysts in Ultrasound

Julia Santos

DMS 496 Clinical Practicum III

Summer 2017
An Evaluation of Pancreatic Pseudocysts in Ultrasound !2

An Evaluation of Pancreatic Pseudocysts in Ultrasound

An Evaluation of Pancreatic Pseudocysts in Ultrasound !3

Abstract

In this report, the author will discuss her experience of performing a gallbladder ultrasound

examination on Mr. S.W. who presented as an outpatient for abdomen pain and previously

abnormal lab values. Additionally, the reader will also learn about various facets of the pathology

found during this examination - a pancreatic pseudocyst. This will include the common signs and

symptoms, sonographic appearance, and prevalence of pancreatic pseudocysts. The author’s

hope in reporting this case is to make other new sonographers aware of a fairly common

abdominal pathology and how it typically manifests itself.

Keywords: pancreas, pseudocysts, abdomen, pancreatitis, ultrasound

An Evaluation of Pancreatic Pseudocysts in Ultrasound !4

Introduction

S.W. presented as an outpatient to the hospital for abdomen pain and previously abnormal

lab values. Through ultrasound examination, it was discovered that he had a large complex cyst

on the anterior portion of the pancreas body. He was later diagnosed with a pancreatic

pseudocyst. These types of pseudocysts are “encapsulated collections of the byproducts of tissue

destruction [that] may contain pancreatic juice, blood, pus, and/or inflammatory byproducts,”

and occur in about 1 of every 1000 people per year 1, 2. The author’s hope in reporting this case is

to make other new sonographers aware of a fairly common abdominal pathology and how it

typically manifests itself.

Case Report

S.W. is a 59 year old Caucasian male who presented as an outpatient to the hospital in

November, 2016 for previously abnormal lab values and abdomen pain. S.W. has a history of

pancreatitis, hypertension, and supraventricular tachycardia. In the patient’s chart review, it is

noted that S.W. drinks about two or three beers a week. When interviewed during his ultrasound

examination, S.W. shared that his current abdomen pain - epigastric pain that radiated towards

his back - resembled that of his acute pancreatitis. Exactly one month prior to this ultrasound

examination, the patient presented to the emergency department for sudden onset of nausea,

dizziness, and abdomen pain. In the days following, he underwent multiple imaging

examinations that led to his initial pancreatitis diagnosis. This included CTs, an MRI, and a

gallbladder ultrasound, none of which showed the cystic lesion that S.W. presented with in his

November ultrasound.
An Evaluation of Pancreatic Pseudocysts in Ultrasound !5

During these previous imaging examinations, initial CT results revealed a hypodense area

within the head/neck of the pancreas which had lost normal border definition (Figure 1). A few

days after the initial CT, follow-up CT and ultrasound examinations showed the area

progressively resolving into a smaller, more cystic area. No more examinations were performed

between then and the gallbladder examination performed by the student in November.

The gallbladder examination performed revealed a fairly large complex lesion directly

anterior to the pancreas (Figure 2). The primarily cystic lesion had a thick, echogenic component

in the posterior portion, a thick wall, and measured 8.85 x 5.24 x 8.59cm (9.30 x 5.96 x 9.15cm

with wall) (Figure 3a and 3b). Color Doppler showed no vascularity relating to the lesion.

Discussion

In the final physician’s report for this examination, the physician stated that the lesion

was most likely a pseudocyst with there being a possibility of it being a hemorrhagic pseudocyst,

and also possibly an abscess. According to Kawamura (2012), “pancreatic pseudocysts [are]

encapsulated collections of the byproducts of tissue destruction [and] may contain pancreatic

juice, blood, pus, and/or inflammatory byproducts” 1. Pseudocysts affect primarily men, occur in

about 1 of every 1000 adults every year, and are a common complication of acute pancreatitis 2.

They tend to develop in the weeks to months following the onset of acute pancreatitis.

When related to pancreatitis, pseudocysts are typically the result of an edematous

pancreas necrotizing. However, they can also be a result of regular alcohol consumption. In fact,

according to Habashi & Draganov (2009), about 59-78% of pseudocyst cases are caused by

alcohol use 4. S.W. happens to meet both of these criteria. While pseudocysts can be

asymptomatic, they can also cause “bloating of the abdomen, […] constant pain or deep ache in
An Evaluation of Pancreatic Pseudocysts in Ultrasound !6

the abdomen, which may also be felt in the back, [and] difficulty eating and digesting food” 5. In

October, S.W. presented to the hospital with elevated lipase, and soon after developed increased

WBC levels; however, no labs were gathered between his initial October hospital stay and his

follow-up physical examination with his PCP on November 16th. However, common lab values

in pancreatic pseudocyst cases include amylase and lipase, enzymes produced by the pancreas

that convert starches into simple sugars and breakdown fats into fatty acids, respectively.

Additionally, bilirubin and LFT might be elevated if some sort of biliary tree pathology is

present.

Sonographically, pseudocysts can have a variety of appearances: ‘clean’, completely

cystic appearance with smooth walls; extremely complex with septa and/or debris with thick,

irregular walls and no posterior enhancement; or somewhere in between the two 1. There were no

notes made in regards to S.W.’s follow-up plan, but in most cases, pseudocysts resolve on their

own. If a pseudocyst is larger than 5cm or has been present for more than 6 weeks, it may need

to be treated and/or drained 1. Possible treatment involves CT-guided needle drainage;

endoscopic-assisted drainage using an endoscope; and/or surgical drainage possibly using

laparoscopy 5.

It is important to remember that just because pseudocysts are common, they cannot

always be dismissed without critical consideration. Pseudocysts can look exactly like malignant

cystic neoplasms and have the same physical symptoms. The primary method of differentiating

the two is either evaluating the patient’s labs or determining if the patient has had any sort of

benign pancreatic disease in the past. Patients who have had complications such as pancreatic

pseudocysts or pancreatitis in the past are more likely to develop pseudocysts again.
An Evaluation of Pancreatic Pseudocysts in Ultrasound !7

Sonographers should always review a patient’s medical history and labs so they can have a good

idea of what to expect when scanning.

Conclusion

In conclusion, a 59 year old Caucasian male named S.W. presented as an outpatient to the

hospital in November, 2016 with previously abnormal lab values and abdomen pain. Through an

ultrasound gallbladder examination, the physician determined that S.W. had a pseudocyst. S.W.’s

scenario is a classic case of a pancreatic pseudocyst. He regularly consumes alcohol, was

recently diagnosed with acute pancreatitis, and had the classic symptom of abdomen pain that

radiates to the back. If a sonographer keeps the discussed pieces of information in mind when

scanning patients with similar medical histories, they will find great success in identifying

pancreatic pseudocysts in the future.



An Evaluation of Pancreatic Pseudocysts in Ultrasound !8

References

1. Kawamura DM, Lunsford BM. Diagnostic Medical Sonography: Abdomen and Superficial

Structures. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012.

2. Cleveland Clinic. Pancreatic Cysts and Pseudocysts. ClevelandClinic.org. http://

my.clevelandclinic.org/health/articles/pancreatic-cysts-and-pseudocysts. Reviewed

4/24/2014. Accessed February 25, 2017.

3. Lambiase L. Epidemiology. Pancreatic Pseudocysts. Medscape.com. http://

emedicine.medscape.com/article/184237-overview Updated 11/21/2016. Accessed February

25, 2017.

4. Habashi S, Draganov PV. Pancreatic pseudocyst. World J Gastroenterol. 2009;15(1):38–47.

doi:10.3748/wjg.15.38

5. U.S. Department of Health and Human Services. Pancreatic Pseudocyst. MedlinePlus.gov.

https://medlineplus.gov/ency/article/000272.htm. Reviewed 10/27/2015. Accessed February

25, 2017.