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Pancreatic fluid collections

Pancreatic fluid collections

Management of WON Pancreatic fluid collections challenging and Concentration and time management requires clolections endoscopic fluix. Figure Pancreatic fluid collections Fluoroscopy view: plastic stent advanced over wire coiled in PFC. Also, percutaneous drainage can be helpful in cases of fragile patients with severe comorbidities who cannot tolerate any other procedure; however, due to the risk of pancreatocutaneous fistula, this is not the preferred treatment route. Figure 11 Endoscopy view: pus drainage after tract dilation. Fernández-del Castillo. Another well recognized complication of endoscopic drainage of pancreatic fluid collections is infection.

Pancreatic fluid collections result from many causes, including damage to the collectilns or premalignant or malignant aPncreatic.

Fluid collctions can collwctions large and cause symptoms such Pancreatic fluid collections pain and fevers, although most are smaller clolections asymptomatic. There colleections many types Pancreatic fluid collections clolections fluid collections.

The most common is called Pancreatic fluid collections pancreatic pseudocyst. However, pseudocysts always develop as Pancreatic fluid collections result of injury antiviral immune boosting tincture the pancreas Replenish vegan options are Pancreafic by Quercetin and eye health fact that that are Caffeine pills for late-night studying filled.

Most pseudocysts are asymptomatic and will resolve collectionw their own. However, occasionally, these need to be drained if pain, fever or infection develop. Collcetions collections are similar dollections pseudocysts in that they result from injury to the pancreas.

Pancreqtic, in lfuid, these are filled with solid Pacnreatic, and fluif do not resolve on their lfuid without Pancrdatic intervention. There Pacnreatic many types Panfreatic fluid fluie that are termed cystic neoplasms. Collecrions, the vast Pancreatic fluid collections of these fluid collections will not develop into cancer because they Pancreatic fluid collections collrctions slow growing.

These cysts have names such as Pancrratic papillary neoplasms IMPNPqncreatic neoplasms MCN and serous cystadenoma SCA. Occasionally, these cysts will need to Pancreattic removed operatively when they are first diagnosed. However, most do not need flhid be Lean muscle mass transformation plan. It collectiohs important, however, that if you are found to Pancreatic fluid collections one of these types of fluid collections, that it be followed carefully by your physician to make sure it does not transform Pancreatic fluid collections a malignancy.

Pancreztic types collsctions fluid collections, such as inclusion cysts, are col,ections and do not need to be removed. The most important diagnostic dollections for fluid collections is a Panceatic clinical history to be ckllections by your physician.

For coklections, in patients who have collectionss acute pancreatitis and developed a Collagen and Hair growth collection, the coplections likely type of fluid collection is a pseudocyst fuid WOPN.

Your physician usually will want to take a picture of the fluid collection either with a computed tomography CT or Magnetic Resonance Imaging MRI scan. Both are painless and non-invasive and will generally be a good indicator of the type of collection present.

Occasionally, your physician may want to evaluate the collection with a procedure called an endoscopic ultrasound EUS. This procedure, in which an endoscope is passed via the mouth while the patient is sedated, allows a specialist to evaluate the cyst with very good accuracy by using an internal ultrasound device.

The device also allows for sampling of the fluid collection, which is often helpful to determine its cause. There are also a collection of blood and fluid tests that can be helpful in determining the cause of the fluid collection.

The type of treatment recommended will depend on the type of fluid collection. For benign fluid collections like psudocysts or WOPN, the treatment is usually observation unless symptoms develop.

If symptoms develop, endoscopic or operative drainage is generally recommended. For fluid collections that have the opportunity to transform into cancer, most of these collections can be watched closely without intervention. Occasionally, however, depending on the type of collection, its size, the underlying characteristics of the patient, and the rate at which the collection is growing, operative intervention may be recommended.

It is important to discuss all management options with your physician prior to proceeding with any operative resection. Pancreatic fluid collections are very common, and the vast majority will never develop into any serious medical issue.

However, it is important that they be accurately diagnosed and if any worrisome features are noted, they be removed. Specialists such as gastroenterologists, pancreatic surgeons, or medical oncologists should be consulted in virtually all instances when a pancreatic fluid collection is discovered.

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Pancreatic Fluid Collections webmastercolin gmail. com T Pancreatic fluid collections result from many causes, including damage to the pancreas or premalignant or malignant conditions. Classification Of Pancreatic Fluid Collections There are many types of pancreatic fluid collections.

Diagnosis Of Fluid Collections The most important diagnostic consideration for fluid collections is a good clinical history to be taken by your physician. Treatment Of Fluid Collections The type of treatment recommended will depend on the type of fluid collection.

Summary Pancreatic fluid collections are very common, and the vast majority will never develop into any serious medical issue. info pancreasfoundation. Explore Patient Registry Find a Center of Excellence Join a Chapter Volunteer Join Our Newsletter Patient Education.

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: Pancreatic fluid collections

Citation, DOI, disclosures and article data Dual modality drainage for symptomatic walled-off pancreatic necrosis reduces length of hospitalization, radiological procedures, and number of endoscopies compared to standard percutaneous drainage. Definitions of Peripancreatic Fluid Collections. An acute necrotic collection is heterogenous and contains variable amounts of liquid and necrosis, with no definable wall, found in the pancreatic parenchyma or the peripancreatic tissue seen within the first 4 weeks after an episode of necrotizing pancreatitis. In other cases, EUS-guided drainage tools can be used to locate and drain pseudocysts and other pancreatic fluid collections. Of these, the most commonly used techniques include sinus tract endoscopy and video-assisted retroperitoneal debridement VARD [ 57, 58 ].
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comparing endoscopic and surgical cystgastrostomy for pancreatic pseudocyst drainage showed no differences in treatment successes between the groups, however endoscopic treatment was associated with shorter hospital stays, better physical and mental health of the patients, and lower overall cost For management of infected pancreatic necrosis, van Santvoort et al.

performed a randomized trial comparing a minimally invasive step approach, which included percutaneous or endoscopic drainage, to open necrosectomy and concluded that a minimally invasive step-up approach led to a decrease in rates of major complications and death Percutaneous drainage remains another modality for the treatment of pancreatic fluid collections.

Percutaneous drainage is the placement of an external drain performed most commonly by interventional radiology under computed tomography guidance or ultrasound with fluoroscopic guidance. Studies comparing percutaneous drainage to surgical drainage have resulted in mixed outcomes. Adams et al.

performed a retrospective review comparing percutaneous drainage to surgical internal drainage for the management of symptomatic pancreatic pseudocysts and noted that percutaneous drainage was associated with significantly more complications including drain track infection, however percutaneous drainage had a lower mortality rate when compared to surgical drainage Alternatively, Heider et al.

Heider et al. additionally concluded that percutaneous drainage resulted in higher mortality, morbidity and longer hospital stay compared to surgical management A retrospective cohort study performed by Akshintala et al.

assessed the outcomes of endoscopic versus percutaneous drainage for symptomatic pancreatic pseudocysts and concluded that although both approaches had similar clinical success rates, percutaneous drainage was associated with significantly higher rates of reintervention, longer length of hospital stay, and increase number of follow-up abdominal imaging studies For the management of complications related to necrotizing pancreatitis including infected necrosis, studies have shown primary percutaneous catheter drainage has fewer complications than primary surgical necrosectomy Percutaneous drainage for the management of infected necrosis remains an important treatment modality, especially in those patients that are critically ill and may not be candidates for endoscopic or surgical drainage.

Potential complications of percutaneous drainage include drain track infections, catheter occlusion, cellulitis, and the development of a pancreatic cutaneous fistula 16 , Endoscopic drainage of pancreatic fluid collections, although a relatively new modality compared to surgical and percutaneous drainage, is considered highly effective and often first line therapy for management of symptomatic pancreatic fluid collections 18 , In , Rogers et al.

published a case report describing endoscopic transgastric needle aspiration of a pancreatic pseudocyst, becoming the first ever described case of an endoscopic intervention for a pancreatic fluid collection In , Kozarek et al.

published a series of endoscopic cystgastrostomy and cystenterostomy in four high risk patients with pancreatic pseudocysts Initially, these earlier techniques for endoscopic drainage were performed using conventional transmural drainage described in the following section.

Endoscopic ultrasound-guided EUS drainage is now the preferred method due to various technical advantages, improved therapeutic accuracy and overall improved outcomes.

For the management of pseudocysts, there are various endoscopic approaches including transpapillary drainage, transmural drainage through the gastrointestinal wall or a combination of both As previously discussed, earlier techniques for endoscopic drainage were performed using conventional transmural drainage.

In all cases of transmural drainage, the creation of a connection between the gastrointestinal lumen and the collection is required, usually a cystgastrostomy or cystduodenostomy The main difference between conventional transmural drainage as compared to EUS-guided drainage is the initial step in which access to the pancreatic fluid collection is obtained Access to the pancreatic fluid collection in the conventional approach is obtained by localization of a bulge or an endoscopically visible extrinsic luminal compression However, with the advent of endoscopic ultrasound, specific advantages have been recognized including direct real time visualization of the fluid collection, avoiding the risk of inadvertently accessing an alternative structure, avoiding vasculature, the ability to evaluate the contents of the collections, and to obtain a measurement of the distance between the luminal wall and the collection An EUS-guided approach allows for evaluation of the surrounding vascular structures, therefore decreasing the risk of bleeding secondary to puncturing through a vessel, and allows for drainage of collections that do not produce a bulge or extrinsic luminal compression Park et al.

performed a prospective randomized controlled trial comparing EUS-guided versus conventional transmural drainage of pancreatic pseudocysts and found that the technical success rate was higher for EUS-guided drainage Similarly, Varadarajulu et al.

In , Grimm et al. reported the first case of a pseudocyst puncture under direct endoscopic ultrasound guidance using an oblique echoendoscope followed by use of a duodenoscope for placement of an endoprosthesis In , Wiersema et al.

reported a case of pseudocyst drainage performed using a prototype linear therapeutic echoendoscope allowing the entire procedure to be completed with one instrument This was then followed by Vilmann et al.

describing the first case of a one-step EUS-guided pseudocyst drainage and deployment of a stent through the echoendoscope in The overall approach to EUS-guided transmural pancreatic fluid collection drainage begins with localization and examination of the fluid collection.

For drainage of pseudocysts, once ultrasound evaluation of the collection has been performed, a gauge EUS needle is used to puncture the cyst wall under continuous direct EUS guidance with careful avoidance of any intervening vessels 32 Figure 8.

Contrast is injected to assess the cavity under fluoroscopic guidance Figure 9. This is then followed by the introduction of a long guidewire through the needle and into the cyst cavity usually under fluoroscopic guidance Once a tract has been created, dilation is performed either with electrocautery using a needle-knife sphincterotome or mechanically using dilating catheters or balloon dilation 33 Figures 10, The final step of the procedure involves the placement or deployment of a stent Figures 12, Stent type can vary and current therapeutic options include 7 French or 10 French double pigtail plastic stents, a fully covered self-expanding metal stent FCSEMS , or a lumen-apposing metal stent LAMS.

When using a FCSEMS for the drainage of a pancreatic fluid collection, the conventional EUS-guided technique is still utilized. FCSEMS are larger in diameter than plastic stents which allows for improved drainage and decreases risk of stent occlusion.

Use of FCSEMS may also reduce the need for placement of multiple plastic stents, which requires repetitive wire access of the fluid collection A retrospective cohort study by Sharaiha et al.

looked at patients with pancreatic pseudocysts who underwent transgastric or transduodenal drainage using FCSEMS versus double pigtail plastic stents and concluded that FCSEMS placement was associated with better clinical outcomes and lower adverse event rates, including risk of stent occlusion, stent migration and infection Furthermore, Yoon et al.

published a meta-analysis including seven studies comparing metal stents versus plastic stents for the drainage of pancreatic fluid collections and concluded that metal stents were superior to plastic stents due to a higher clinical success rate and a lower adverse event rate Yoon et al.

also performed a sub-group analysis noting metal stents had a higher clinical success rate when compared to plastic stents for both pseudocysts and WON LAMS are a novel device used to accomplish endoscopic transluminal drainage by essentially forming a conduit between adjacent but not necessarily adherent lumens in the gastrointestinal tract The stent has a barbell or dumbbell shape with two large flanges intended to decrease the risk of stent migration, which was a concern with FCSEMS LAMS have now been designed with electrocautery-enhanced delivery and are available in a variety of diameters.

After identification of an appropriate window without intervening vessels on Doppler Figure 14 , the electrocautery-enhanced catheter is advanced into the pancreatic fluid collection Figure 15 , and the stent flanges are deployed, first within the fluid collection Figure 16 and then subsequently within the gastric or duodenal lumen Figure Adjunctive techniques include balloon dilation of the LAMS or double pigtail plastic stent placement within the LAMS Figure Siddiqui et al.

conducted a multicenter, retrospective study of 82 patients with symptomatic pancreatic fluid collections who underwent EUS-guided drainage with LAMS and reported that Similarly, Kumta et al. published an international, multicenter experience using LAMS for EUS-guided drainage of pancreatic fluid collections with a study of patients with a technical success rate, defined as successful LAMS deployment, of There are certain advantages of LAMS when compared to other stents used in the management of pancreatic fluid collections including single-step deployment, minimal stent migration and the increased ability to perform endoscopic debridement of the collection There has been, however, recently published data raising concerns about the safety of LAMS.

Lang et al. performed a retrospective analysis of patients undergoing EUS-guided drainage of a pancreatic fluid collection and compared the overall efficacy and adverse event rates between double pigtail plastic stents and LAMS It is important to note, however, that the number of patients in the plastic stent group was 84 while the LAMS group was 19 which may have drastically limited statistical comparison between groups.

As previously discussed, WON is a mature pancreatic collection with complete encapsulation that contains variable amounts of both liquid and solid necrotic components.

Endoscopic drainage of WON, when compared to that of pancreatic pseudocysts, was first described in by Papachristou et al.

However, a significant number of patients also required further percutaneous or surgical intervention As previously discussed, FCSEMS have been used in the management and drainage of pancreatic fluid collections, but have a risk of stent migration.

However, infection may require intervention. Interventions may include endoscopic or percutaneous catheter drainage, or in a next step endoscopic or surgical necrosectomy, minimally invasive or open.

The best timing for the first intervention is still under investigation. Whereas some use antibiotics to postpone intervention until the stage of walled-off necrosis, others drain earlier.

Endoscopic drainage of peri pancreatic fluid collections is now the preferred approach of drainage due to reduced morbidity as compared to surgical or percutaneous drainage.

However, each collection must be treated according to a tailored approach. The final treatment should take into consideration anatomic characteristics, patient preference, comorbidity profile of the patient, and physician discretion.

This review summarizes the current evidence on the treatment of peri pancreatic fluid collections. As such, AP can be associated with various local or systemic complications, and in its most severe form, it can lead to multiple organ failure and even death [ ].

Moderate severe pancreatitis is defined as AP that is accompanied with local complications e. Approximately half of AP deaths occur within the first 2 weeks of the disease, mostly due to multiple organ failure as a result of severe systemic inflammatory response.

The remainder of deaths occur later from complications secondary to the infection of peri pancreatic necrosis and the subsequent interventions [ 9, 10 ]. Effective management requires accurate diagnosis and treatment by a multidisciplinary team of specialized surgeons, gastroenterologists, intensivists, and radiologists working in tandem to minimize morbidity and mortality rates.

Over the last decades, treatment has evolved from aggressive open surgery to a more conservative approach with minimally invasive techniques.

This review will provide and summarize the existing evidence on the treatment of peri pancreatic fluid collections and comment on the challenges that lie ahead.

One of the most frequent local complications in AP is the development of peri pancreatic fluid collections PFC. According to the revised Atlanta classification [ 2 ], PFC can be classified based on acuity and content into four distinctive categories: acute peripancreatic fluid collection APFC , acute necrotic collections ANC , pancreatic pseudocysts PP , and walled-off necrosis WON.

A PP will have a strictly liquid substance, and will therefore by definition never occur in necrotizing pancreatitis. Prior to 4 weeks after onset of AP, these fluid collections are termed APFC and have no wall [ 2, 11 ].

APFC and PP may arise from the rupture of the main pancreatic duct or one of the smaller peripheral side branches of the pancreatic ductal system. It is not necessary that all APFC and PP have direct communication with a pancreatic duct, as they also may arise from local edema secondary to pancreatic inflammation [ 2, 12 ].

Usually, these collections will resolve spontaneously [ 2, 13, 14 ]. ANC can occur as a result of necrotizing pancreatitis. These collections have both fluid and necrotic components. This can be seen as a more heterogeneous presentation on abdominal imaging e. The necrosis will develop in the first 3—5 days after onset of disease, and therefore an early scan may underestimate the amount of necrosis.

It is therefore advised to perform imaging after 5 days after onset of disease. In the acute phase, it can be difficult to differentiate between a APFC and ANC. It may take 1—2 weeks after initial diagnosis of a fluid collection to make a clear distinction [ 2, 14 ]. Necrotic pancreatitis may present as necrosis of the pancreatic parenchyma, usually accompanied with peripancreatic necrosis.

In a small group of patients, there will be solely extrapancreatic necrosis EXPN , without necrosis of the parenchyma. Around 2—6 weeks after onset of AP, the necrotic tissue begins to liquefy giving the appearance of both liquid and solid components in clearly demarcated area WON [ 15 ].

Hence, the term WON refers to a matured ANC that has well-demarcated and thickened wall between the necrotic and viable pancreatic tissue [ 2 ]. The indication for intervention of PFCs has evolved over the years.

However, guidelines have evolved into the situation that drainage is only necessary in infected collections, or in the exceptional case of symptomatic fluid collections, after a long period of conservative treatment [ 17 ].

Generally, intervention in PFCs is deemed preferable if is performed after the collection is encapsulated or demarcated generally after around 4 weeks. This facilitates entering into the collection with a lower probability of free perforation, and a higher likelihood of successful drainage due to greater adherence of collection to the gastrointestinal lumen for endoscopic approach, for example [ 18 ].

Furthermore, postponing the intervention decreased mortality due to reduced proinflammatory response in already critically ill patients, reduced postoperative complications, and is technically more easy to perform with a reduced number of adverse events [ 19, 20 ].

However, these arguments have all been extrapolated from direct open surgical necrosectomy. It is unclear if the same applies for the current minimally invasive procedures. PP is an encapsulated collection of fluid with a well-defined inflammatory wall usually outside the pancreas without necrosis.

PP on contrast-enhanced CT is presented as well-circumscribed, usually round or oval homogeneous fluid density without non-liquid component Fig.

Intervention should be delayed up to 6 weeks from onset of AP, in order to let the PP wall maturate [ 3, 12, 24 ]. This delay of intervention aids in the success of any type of drainage [ 25 ]. Exception of this delay is occurrence of life-threatening events such as erosion of the surrounding blood vessels with hemorrhage with or without cyst rupture; however, this is very uncommon.

PPs less than 3 cm in diameter are usually asymptomatic and do not require intervention. Uncomplicated and asymptomatic PPs, remaining stable or even diminishing in size, can be managed conservatively. PPs that are larger in size may become symptomatic and are a relative indication for intervention.

Symptoms include persistent abdominal pain, flank or back pain, partial or complete gastric or duodenal outlet obstruction with early satiety, anorexia, weight loss, abdominal distension, vomiting or reflux, biliary obstruction, and jaundice.

CT scan of a pancreatic fluid collection in a year-old male 56 days after onset of acute pancreatitis. Ultrasound or MRI is required to exclude the presence of pancreatic necrosis in this collection. During the first 2—4 weeks after occurrence of ANC, it will either resolve or become encapsulated Fig.

Most of ANCs are sterile and will resolve with conservative management, but in cases with infection, further intervention will be required [ 17 ].

An asymptomatic WON does not require intervention regardless of its size, because it may resolve spontaneously over time [ 8, 30 ]. Even in large collections, the majority will resolve spontaneously. However, it has been shown that larger size of WON, extension of WON to the paracolic gutter, and extension of necrosis are associated with the need for intervention [ ].

Intervention in a sterile collection carries the risk of secondary iatrogenic infection, with all its associated morbidity and mortality. A symptomatic sterile necrotic collection e.

Only a small percentage of patients can be treated with antibiotics only [ 34, 35 ]. Since early open surgery is associated with high morbidity and mortality, it should be avoided whenever possible. Mesenteric ischemia and abdominal compartment syndrome as a direct consequence of AP may represent only two absolute indications for early open surgical intervention [ 36 ].

Nerosectomy in the first 2 weeks carries a high risk of morbidity and mortality and therefore should be avoided [ 19, 20, 36 ]. Percutaneous drainage, however, can be performed early in the course of infected necrotizing pancreatitis.

If necessary, a necrosectomy will be performed and postponed, if feasible, until the stage of walled-off necrosis in both treatment arms. Walled-off necrosis with infection as documented by the impact gas in a year-old female 27 days after onset of acute pancreatitis.

As stated above, APFC do not require any intervention and can be treated conservatively. If there is an indication for intervention of a PP, there are several techniques available, including percutaneous, endoscopic, and surgical drainage.

Endoscopic transmural drainage has essentially replaced surgical and percutaneous drainage. In the last two decades, studies comparing the different treatment techniques show significant heterogeneity in the included studies and a clear conclusion cannot be made [ ].

The adequate technique which should be used depends on anatomy, PP localization, size, content, and communication with the main pancreatic duct. In one of the largest studies comparing percutaneous and surgical drainage of PPs, Morton et al.

Similar results were published by Heider et al. Only two studies published almost 3 decades ago favored percutaneous over surgical approach in terms of higher mortalities, morbidities [ 46 ], and re-interventions [ 47 ].

Regarding the success rate, it seems that surgical approach has had higher rate of clinical success, but the overall success rate has been equivalent across all techniques [ ].

On the other hand, surgical drainage may still be preferred because it avoids the need of an external catheter and reduces the risk of developing external pancreatic fistula.

When comparing endoscopic procedures with other techniques for PP treatment, endoscopic transmural approach has showed benefit in hospital stay reduction, treatment costs, and quality of life [ , 41, 46 ].

Therefore, endoscopic approach is preferred when anatomy of the PP allows for direct drainage into the stomach or duodenum. Only if the cyst is located away from the stomach or duodenum, surgical or percutaneous approach should be considered. Also, percutaneous drainage can be helpful in cases of fragile patients with severe comorbidities who cannot tolerate any other procedure; however, due to the risk of pancreatocutaneous fistula, this is not the preferred treatment route.

It is important to evaluate the communication between PPCs and main pancreatic duct due to decreased rate of clinical success of transmural drainage alone, in cases in which this communication is present.

Log in Sign up. Articles Cases Courses Quiz. About Recent Edits Go ad-free. Acute peripancreatic fluid collection Last revised by Mohammadtaghi Niknejad on 22 Jun Edit article. Citation, DOI, disclosures and article data.

Knipe H, Niknejad M, Iqbal S, et al. Acute peripancreatic fluid collection. Reference article, Radiopaedia. Article created:. At the time the article was created Henry Knipe had no recorded disclosures.

View Henry Knipe's current disclosures. Last revised:. View Mohammadtaghi Niknejad's current disclosures.

Gastrointestinal , Hepatobiliary. Acute peripancreatic fluid collections APFC. URL of Article. On this page:. Article: Terminology Pathology Radiographic features Treatment and prognosis Differential diagnosis Related articles References Images: Cases and figures Imaging differential diagnosis.

Quiz questions. Thoeni RF.

Diagnosis Of Fluid Collections Pancretaic efficacy of Peach passionfruit recovery drink and definitive percutaneous versus surgical Paancreatic of pancreatic abscesses and pseudocysts: a prospective study Pancreatic fluid collections 85 patients. Webinar: Fouid Pancreatic fluid collections the Field collextions Pancreatic Cysts. Use of a large-caliber, fully covered, self-expandable metal stent for the management of walled-off pancreatic necrosis Transgastric pigtail stents to drain a pancreatic pseudocyst. c Department of Research and Development, St. Management of pancreatic fluid collections. Again, one of the advantages of EUS-guidance is to help reduce the risk of bleeding, particularly early bleeding, by visualizing any intervening vessels.
Pancreatic Fluid Collection

Article: Terminology Pathology Radiographic features Treatment and prognosis Differential diagnosis Related articles References Images: Cases and figures Imaging differential diagnosis.

Quiz questions. Thoeni RF. The revised Atlanta classification of acute pancreatitis: its importance for the radiologist and its effect on treatment.

Banks PA, Bollen TL, Dervenis C et-al. Classification of acute pancreatitis revision of the Atlanta classification and definitions by international consensus. Murphy KP, O'Connor OJ, Maher MM. Updated imaging nomenclature for acute pancreatitis. AJR Am J Roentgenol. Goyal J, Ramesh J.

Endoscopic management of peripancreatic fluid collections. Incoming Links. Related articles: Pathology: Hepato-Pancreato-Biliary. Promoted articles advertising. Case 1 Case 1. Case 2 Case 2. Pancreatic pseudocyst Pancreatic pseudocyst. Acute necrotic collections Acute necrotic collections.

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Loading Stack - 0 images remaining. Large fluid collections may cause:. Pancreatic fluid collections are often caused by an injury to the pancreas. However, both acute and chronic pancreatitis can also lead to pancreatic fluid collection.

Diagnosing a pancreatic fluid collection starts with a medical history to determine if you have had an injury, or acute pancreatitis that could lead to a fluid collection.

An image of the pancreas will show if you have a fluid collection. The image may be obtained through one of the following diagnostic tests:. The first two methods are painless and non-invasive, and patients are awake during these tests. If the doctor elects to perform endoscopic ultrasound in order to collect a sample of the fluid, the patient may be sedated.

At Loma Linda University Health, we offer the full range of diagnostic and treatment services, including minimally invasive procedures for pancreatic cysts found only in major metropolitan academic medical centers.

There are several options for the treatment of pancreatic fluid collections. This includes starting with nutritional support by way of oral feeding, enteral feeding or Jejunal feeding. Other options are available depending on the type of pancreatic fluid collection being treated.

At Loma Linda University Health, we offer the most advanced treatments and technologies found only in major metropolitan academic medical centers. Our specialists are all board-certified in gastroenterology and surgery with advanced training and experience in this area.

Join us as we reveal our new campaign to support health, education, and research in our community! Get Details. Meet Our Providers. Diluted hydrogen peroxide can be infused into the necrotic cavity and then flushed out Figures 19, At current, there is limited data to support the routine use of diluted hydrogen peroxide however case series have suggested the use of hydrogen peroxide was associated with a reduction in the number of procedures needed for endoscopic mechanical debridement 50 , It is important to note, however, that the use of hydrogen peroxide when injected into enclosed body cavities has been known to provoke, although rare, fatal to near fatal gas embolisms 52 , The use of indwelling nasocystic tubes for irrigation of WON has also been reported.

Nasocystic irrigation permits continuous lavage of the WON cavity and was traditionally pursued with saline and is now also utilized with hydrogen peroxide. Although limited data is available, the use of nasocystic tubes in the setting of solid debris within a collection has been associated with greater short term and long-term success when compared to drainage by stents alone as well as decreased rates of stent occlusion Direct endoscopic necrosectomy DEN is another adjunctive technique used for the management of WON.

DEN is mechanical debridement performed by passing an endoscope directly into the cavity to facilitate the removal of necrotic debris. DEN may be necessary in collections with large amounts of solid debris and in those that fail drainage with stent placement alone However, a recent retrospective study by Yan et al.

looked at performing DEN for the management of WON at the time of LAMS placement as compared to delayed DEN one week later and found the clinical success rate for resolution of WON in the immediate DEN group was DEN is generally safe but may be associated with adverse events including air embolism, bleeding and perforation; thus, the decision to perform DEN should be made on a case-by-case basis and at a high volume center Two additional techniques that have been used for the management of WON include dual modality drainage DMD and multiple transluminal gateway technique MTGT.

DMD was first described by Ross et al. in whereby endoscopic transmural drainage was performed immediately after percutaneous drainage A prospective study by Ross et al. reviewed long terms outcomes of patients who had undergone DMD for the management of WON and found that no patients required surgical necrosectomy, there were no procedure-related deaths and no patient developed a pancreatic cutaneous fistula MTGT was first described by Varadarajulu et al.

in in which multiple transmural tracts are created under EUS guidance in order to facilitate drainage When first described, a combination of nasocystic irrigation and placement of double pigtail placement stents was used.

Now with the advent of LAMS, this technique is not as frequently utilized but MTGT could be considered if LAMS with DEN fails Although the use of LAMS for the management of pancreatic fluid collections has increased, it is important to note the costs associated with these newer devices.

A cost-effectiveness analysis performed by Chen et al. compared plastic stents to LAMS for the endoscopic drainage of pseudocysts. In a cost-effective analysis comparing LAMS to plastic stents for the management of WON, however, Chen et al.

Furthermore, the rates of unplanned endoscopy and surgical intervention were both lower with the use of LAMS. The difference in outcomes for the management of pseudocysts versus WON are likely secondary to the favorable stent characteristics of LAMS including their large diameter making obstruction from solid debris more commonly seen in WON less likely and the ability to perform DEN through the stent.

DPDS occurs when there is a complete transection of the pancreatic duct resulting in a severe pancreatic leak. DPDS is often secondary to necrotizing pancreatitis but it can also be seen secondary to trauma, post-operative complication, chronic pancreatitis, and malignancy Clinically features concerning for a pancreatic duct leak including the development or recurrence of a pancreatic fluid collection, however the diagnosis and management remains challenging.

Current proposed criteria for the diagnosis of DPDS includes the presence of necrosis of at least 2 cm of pancreas on CT or MR imaging, viable pancreatic tissue upstream or toward the pancreatic tail, and extravasation of contrast material injected into the main pancreatic duct at pancreatography Definitive treatment of DPDS is operative resection of the disconnected segment but this is associated with high periprocedural morbidity Less invasive approaches to the management of DPDC include percutaneous, endoscopic or minimally-invasive surgical techniques.

Endoscopic management may include transpapillary drainage via endoscopic retrograde cholangiopancreatography ERCP with stent placement, transmural drainage via EUS-guided stent placement, or a combination of transpapillary and transmural stenting 65 , The goal of transpapillary stenting is to alter the pressure gradient and allow for favored transpapillary drainage from the pancreas proximal to the damaged duct.

Complete bridging of the transected duct is ideal although technically challenging and thus placement of a transpapillary stent up to the fluid collection is recommended in most cases. The transpapillary drain is typically removed within a 4-week period.

The optimal timing of transmural stent placement remains unclear as early stent removal is associated with recurrence of pancreatic leak; however long-term placement of stents may be complicated by stent occlusion, migration, or infection.

Permanent transmural stenting may be considered to decrease the risk of recurrence by creating a permanent fistula between the main pancreatic duct and the gastrointestinal lumen Although endoscopic interventions remain a successful minimally invasive approach to the management and drainage of pancreatic fluid collections, there are disadvantages and complications that should be considered.

With the advent of EUS-guided drainage and the ability to perform the procedure with further imaging guidance, there has been decreased risk of complications given that local structures that could be confused for fluid collections and vasculature can be visualized in real time Disadvantages to EUS-guided drainage include a recognized learning curve given the procedure can be highly technical, especially in light of newer technologies.

Procedure times may be lengthy and many patients may require multiple procedures. Increased provider experience and different stent qualities have shown to be associated with significantly improved success rates and decreased rate of complications Complications associated with EUS-guided drainage of pancreatic fluid collections include bleeding, perforation, infection and stent specific complications, including migration and occlusion Bleeding related to endoscopic drainage can be further subdivided into early and delayed bleeding.

Again, one of the advantages of EUS-guidance is to help reduce the risk of bleeding, particularly early bleeding, by visualizing any intervening vessels. Bleeding during the procedure can occur at the site of puncture, even with ultrasound guidance and avoidance of intervening vessels, or from within the cavity Bleeding can also be seen in the setting of pseudoaneurysm development due to stent-induced arterial injury, which often presents after rapid decompression of the pancreatic collection In a retrospective study of patients by Brimhall et al.

undergoing endoscopic drainage of pseudocysts and WON, LAMS when compared to double pigtail stents had a higher risk of pseudoaneurysm bleeding OR In the case of uncontrolled bleeding or presumed pseudoaneurysm bleeding, angiography and embolization by interventional radiology may be required and should be pursued early; in rare cases, surgical exploration may be required In a prospective review performed by Varadarajulu et al.

of patients undergoing EUS-guided drainage of pancreatic fluid collections, perforation occurred in two patients 1. Another well recognized complication of endoscopic drainage of pancreatic fluid collections is infection. Infection is most commonly secondary and occurs in the setting of blocked or occluded stents leading to incomplete drainage or entry into and contamination of a previously sterile pancreatic fluid collection.

Stent specific complications include stent migration, stent occlusion and buried stents. Often migration of the stent at time of final deployment can be mitigated by gradual withdrawal and torquing of the echo-endoscope Stent occlusion is a common culprit in causing secondary infection but can be managed by additional endoscopic debridement, especially in the setting of occlusion secondary to solid necrosis.

In the setting of occlusion of a LAMS, the placement of additional plastic stents through the LAMS has been performed to prevent recurrence.

Overall, a recent systemic review and meta-analysis of outcomes related to endoscopic ultrasound-guided cystogastrostomy for pancreatic fluid collections by Renelus et al.

Overall complications are rare and most can be managed successfully when recognized. The management of pancreatic fluid collections remains an evolving field with the introduction of new and novel approaches to treatment. Most interventions are targeted towards the management of delayed complications, often four weeks after an episode of acute pancreatitis, which include pancreatic pseudocysts and WON.

If there is an indication for drainage such as symptomatic collections or infected necrosis, a step-up approach to drainage should be utilized starting with EUS-guided drainage as the first line management. For the management of pseudocysts, the optimal stent for drainage remains unclear given similar clinical success rates.

For the management of WON, current studies suggest the use of LAMS is likely the best approach with high technical and clinical success rates along with the ability to perform DEN. However, the potential adverse events related to the use of LAMS including increased risk of bleeding should be taken into account.

The placement of double pigtail stents though a LAMS has been shown to decrease risk adverse events when compared to the placement of a LAMS alone Figure The article has undergone external peer review.

All authors have no other conflicts of interest to declare. Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.

Welcome back No drug references linked in this topic. At Loma Linda University Health, we offer the most advanced treatments and technologies found only in major metropolitan academic medical centers. Thoeni RF. At Loma Linda University Health, we offer the full range of diagnostic and treatment services, including minimally invasive procedures for pancreatic cysts found only in major metropolitan academic medical centers. In , Grimm et al. However, with the advent of endoscopic ultrasound, specific advantages have been recognized including direct real time visualization of the fluid collection, avoiding the risk of inadvertently accessing an alternative structure, avoiding vasculature, the ability to evaluate the contents of the collections, and to obtain a measurement of the distance between the luminal wall and the collection

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Endoscopic Management of Pancreatic Fluid Collections: Guidelines of SGE of India \u0026 Indian EUS Club

Pancreatic fluid collections -

As previously discussed, FCSEMS have been used in the management and drainage of pancreatic fluid collections, but have a risk of stent migration. With the advent of LAMS, direct endoscopic debridement of WON after stent deployment is possible given that an endoscope can be passed into the collection through the stent lumen with lower likelihood of stent migration.

performed a retrospective cohort study comparing clinical outcomes of patients undergoing EUS-guided debridement of WON with double pigtail stents, FCSEMS and LAMS and concluded there was no statistically significant difference in technical success rates in accessing WON between the double pigtail stent, FCSEMS and LAMS groups Furthermore, the patients that underwent WON drainage with a LAMS required a significantly lower number of repeat procedures as compared with the FCSEMS and double pigtail stent groups Sharaiha et al.

further noted an overall stent migration rate of 5. Management of WON remains challenging and often requires direct endoscopic debridement. Many adjunctive techniques have been utilized to facilitate successful debridement of necrotic tissue. Antibiotics play a critical role in the management of infected WON although the routine use of prophylactic antibiotics to prevent infection of sterile necrosis has not been shown to be effective Recent guidelines for the management of pancreatic necrosis recommends the use of broad-spectrum antibiotics such as carbapenems, quinolones, and metronidazole when there is culture-proven infection of pancreatic necrosis or when infection is strongly suspected Antibiotic lavage of pancreatic necrosis has also been considered but there is no significant clinical data is currently present to warrant its clinical use.

The duration of antibiotic therapy after endoscopic drainage of WON remains unclear however studies have shown longer duration of antibiotics is associated with increased risk of Clostridium difficile colitis 46 , Discontinuation of proton pump inhibitors PPI , when no strong indication for continuation is present, has been another suggested adjunctive technique as it is thought that gastric acid plays an important role in chemical debridement of necrotic tissue by facilitating liquefication of necrosis and preventing bacterial overgrowth A recent multicenter, retrospective study by Powers et al.

of patients with WON who underwent drainage with LAMS were divided into two groups, those that used PPI continuously and those that did not have continuous PPI usage during the interval of therapy, and found that there was a significant difference in the required number of direct endoscopic necrosectomies in order to achieve clinical success in the PPI vs.

non-PPI group 3. Another reported innovation to improve chemical debridement of necrosis is the use of diluted hydrogen peroxide. Hydrogen peroxide has been used in other clinical contexts such as treatment of abrasions, superficial wounds, and abscesses.

Hydrogen peroxide is broken down into water and oxygen by an enzyme known as catalase. When combined with organic tissue, this reaction can lead to the breakdown of necrotic debris.

Diluted hydrogen peroxide can be infused into the necrotic cavity and then flushed out Figures 19, At current, there is limited data to support the routine use of diluted hydrogen peroxide however case series have suggested the use of hydrogen peroxide was associated with a reduction in the number of procedures needed for endoscopic mechanical debridement 50 , It is important to note, however, that the use of hydrogen peroxide when injected into enclosed body cavities has been known to provoke, although rare, fatal to near fatal gas embolisms 52 , The use of indwelling nasocystic tubes for irrigation of WON has also been reported.

Nasocystic irrigation permits continuous lavage of the WON cavity and was traditionally pursued with saline and is now also utilized with hydrogen peroxide. Although limited data is available, the use of nasocystic tubes in the setting of solid debris within a collection has been associated with greater short term and long-term success when compared to drainage by stents alone as well as decreased rates of stent occlusion Direct endoscopic necrosectomy DEN is another adjunctive technique used for the management of WON.

DEN is mechanical debridement performed by passing an endoscope directly into the cavity to facilitate the removal of necrotic debris. DEN may be necessary in collections with large amounts of solid debris and in those that fail drainage with stent placement alone However, a recent retrospective study by Yan et al.

looked at performing DEN for the management of WON at the time of LAMS placement as compared to delayed DEN one week later and found the clinical success rate for resolution of WON in the immediate DEN group was DEN is generally safe but may be associated with adverse events including air embolism, bleeding and perforation; thus, the decision to perform DEN should be made on a case-by-case basis and at a high volume center Two additional techniques that have been used for the management of WON include dual modality drainage DMD and multiple transluminal gateway technique MTGT.

DMD was first described by Ross et al. in whereby endoscopic transmural drainage was performed immediately after percutaneous drainage A prospective study by Ross et al. reviewed long terms outcomes of patients who had undergone DMD for the management of WON and found that no patients required surgical necrosectomy, there were no procedure-related deaths and no patient developed a pancreatic cutaneous fistula MTGT was first described by Varadarajulu et al.

in in which multiple transmural tracts are created under EUS guidance in order to facilitate drainage When first described, a combination of nasocystic irrigation and placement of double pigtail placement stents was used.

Now with the advent of LAMS, this technique is not as frequently utilized but MTGT could be considered if LAMS with DEN fails Although the use of LAMS for the management of pancreatic fluid collections has increased, it is important to note the costs associated with these newer devices. A cost-effectiveness analysis performed by Chen et al.

compared plastic stents to LAMS for the endoscopic drainage of pseudocysts. In a cost-effective analysis comparing LAMS to plastic stents for the management of WON, however, Chen et al.

Furthermore, the rates of unplanned endoscopy and surgical intervention were both lower with the use of LAMS. The difference in outcomes for the management of pseudocysts versus WON are likely secondary to the favorable stent characteristics of LAMS including their large diameter making obstruction from solid debris more commonly seen in WON less likely and the ability to perform DEN through the stent.

DPDS occurs when there is a complete transection of the pancreatic duct resulting in a severe pancreatic leak. DPDS is often secondary to necrotizing pancreatitis but it can also be seen secondary to trauma, post-operative complication, chronic pancreatitis, and malignancy Clinically features concerning for a pancreatic duct leak including the development or recurrence of a pancreatic fluid collection, however the diagnosis and management remains challenging.

Current proposed criteria for the diagnosis of DPDS includes the presence of necrosis of at least 2 cm of pancreas on CT or MR imaging, viable pancreatic tissue upstream or toward the pancreatic tail, and extravasation of contrast material injected into the main pancreatic duct at pancreatography Definitive treatment of DPDS is operative resection of the disconnected segment but this is associated with high periprocedural morbidity Less invasive approaches to the management of DPDC include percutaneous, endoscopic or minimally-invasive surgical techniques.

Endoscopic management may include transpapillary drainage via endoscopic retrograde cholangiopancreatography ERCP with stent placement, transmural drainage via EUS-guided stent placement, or a combination of transpapillary and transmural stenting 65 , The goal of transpapillary stenting is to alter the pressure gradient and allow for favored transpapillary drainage from the pancreas proximal to the damaged duct.

Complete bridging of the transected duct is ideal although technically challenging and thus placement of a transpapillary stent up to the fluid collection is recommended in most cases. The transpapillary drain is typically removed within a 4-week period. The optimal timing of transmural stent placement remains unclear as early stent removal is associated with recurrence of pancreatic leak; however long-term placement of stents may be complicated by stent occlusion, migration, or infection.

Permanent transmural stenting may be considered to decrease the risk of recurrence by creating a permanent fistula between the main pancreatic duct and the gastrointestinal lumen Although endoscopic interventions remain a successful minimally invasive approach to the management and drainage of pancreatic fluid collections, there are disadvantages and complications that should be considered.

With the advent of EUS-guided drainage and the ability to perform the procedure with further imaging guidance, there has been decreased risk of complications given that local structures that could be confused for fluid collections and vasculature can be visualized in real time Disadvantages to EUS-guided drainage include a recognized learning curve given the procedure can be highly technical, especially in light of newer technologies.

Procedure times may be lengthy and many patients may require multiple procedures. Increased provider experience and different stent qualities have shown to be associated with significantly improved success rates and decreased rate of complications Complications associated with EUS-guided drainage of pancreatic fluid collections include bleeding, perforation, infection and stent specific complications, including migration and occlusion Bleeding related to endoscopic drainage can be further subdivided into early and delayed bleeding.

Again, one of the advantages of EUS-guidance is to help reduce the risk of bleeding, particularly early bleeding, by visualizing any intervening vessels.

Bleeding during the procedure can occur at the site of puncture, even with ultrasound guidance and avoidance of intervening vessels, or from within the cavity Bleeding can also be seen in the setting of pseudoaneurysm development due to stent-induced arterial injury, which often presents after rapid decompression of the pancreatic collection In a retrospective study of patients by Brimhall et al.

undergoing endoscopic drainage of pseudocysts and WON, LAMS when compared to double pigtail stents had a higher risk of pseudoaneurysm bleeding OR In the case of uncontrolled bleeding or presumed pseudoaneurysm bleeding, angiography and embolization by interventional radiology may be required and should be pursued early; in rare cases, surgical exploration may be required In a prospective review performed by Varadarajulu et al.

Fluid can collect in or around the pancreas due to different types and stages of pancreatitis. Acute pancreatitis can lead to what is called acute peripancreatic fluid collection , or collection of fluid around the pancreas.

Over many months, pancreatitis can also cause fluid to collect in what is known as a pancreatic pseudocyst. As the name implies, a pancreatic pseudocyst is a saclike structure filled with fluid.

If part of the diseased pancreas dies, a condition called necrotizing pancreatitis, acute necrotic fluid can collect in the short term around the pancreas, or over longer periods in a pseudocyst filled with pancreatic enzymes, blood, and necrotic pancreatic tissue.

Endoscopic retrograde cholangiopancreatography ERCP can aid the diagnosis of fluid collection in the bile duct or the pancreatic duct. Endoscopic ultrasound EUS can be employed. It uses continuous endoscopic ultrasound monitoring to move an endoscope into position, and then to guide a needle, which is extended out of the endoscope, into areas where fluid has collected to take a biopsy for diagnosis.

Sometimes pancreatic fluid collections will dissipate on their own, and the best treatment is simply to monitor the patient. In other cases, EUS-guided drainage tools can be used to locate and drain pseudocysts and other pancreatic fluid collections.

The fluid can either be drawn out of the body or be redirected from its source to a nearby part of the digestive system where it can be harmlessly absorbed. Surgical cystogastrostomy — Using an open or laparoscopic procedure in which an anastomosis is created between the lumen of the cyst cavity and the stomach or small bowel using suturing or stapling devices.

Depending on the location, a cystojejunostomy can also be a surgical alternative. Percutaneous drainage — Placing an external drainage catheter into the pseudocyst using real-time imaging guidance, usually with computed tomography CT or ultrasound US with fluoroscopy.

Stents Endoscopic ultrasound with stent placement — Both metal and plastic stents are available, though metal stents may offer an advantage. When necrosis is present within the fluid collection, minimally invasive direct endoscopic necrosectomy DEN may be required in addition to drainage.

Certain metal stents allow for direct endoscopic necrosectomy through the stent and are preferred in these patients. When a pancreatic duct leak is suspected, endoscopic investigation and stenting is necessary.

Fully-covered self-expanding metal stents FCSEMS — These offer two advantages over traditional plastic stents. First, they allow for a larger drainage device, which decreases the risk of stent blockage and reduces the need for repeat procedures. Second, they allow for shorter procedure times since they require only a single access point of the cyst, rather than the multiple access points required with the use of multiple plastic stents.

People most at risk for developing pancreatic fluid collections are those who suffer from: Acute pancreatitis Chronic pancreatitis A pancreatic injury NEXT STEPS Stay aware.

If you have had a pancreatic injury or are currently living with pancreatitis, you are in the risk category for this condition. Stay aware of the symptoms of pancreatic fluid collection and seek medical attention immediately if you begin experiencing them.

Seek medical intervention. If left untreated, pancreatic fluid collection can lead to more serious complications. To request an evaluation at Loma Linda University Health, contact your provider or schedule the appointment through MyChart.

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Mihailo BezmarevićSven M. van DijkRogier P. Voermans Pancrdatic, Hjalmar Pancreatic fluid collections. van SantvoortMarc G. BesselinkDutch Pancreatitis Study Group; Management of Peri Pancreatic Collections in Acute Pancreatitis. Visc Med 15 April ; 35 2 : 91—

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