Management of Pancreatic Cystic Lesions

Evaluation and Management of Pancreatic Cystic Lesions with Endoscopic Ultrasound and Fine Needle Aspiration.
Presentation by:Praveen Sateesh, M.D., M.H.S.A.
Georgetown Internal Medicine,

Differential Diagnosis of Pancreatic Cystic Lesion.
* Congenital cysts
* Acquired cysts
* Extrapancreatic cysts
* Cystic Pancreatic Tumors
* Serous Cystadenoma
* Mucinous Cystic Neoplasm
* Intraductal Papillary Mucinous Neoplasm

Role of EUS
* Identify architecture of cystic lesion
* Ease of FNA
* Determine type of CPT and malignant potential
* Examination of pancreatic ducts and parenchyma
* Guide surgery

Cystic Fluid Analysis
* Cytology
* Tumor markers
* Amylase

EUS FNA characteristics of certain pancreatic cystic lesions
Retrospective Study
* Preoperative diagnosis of pancreatic cystic lesions remains difficult and no established guidelines for evaluation and management of these lesions.
* Identify cases of cystic pancreatic lesions identified by CT or MR undergone EUS FNA with fluid sent for amylase, CEA, and cytology
* Evaluate performance of EUS findings and FNA findings (cytology, amylase, CEA) as compared to surgical pathology and/or clinical follow up (final diagnosis)
* Number of cases
* Differentiating cysts based on size, location, and EUS characteristics
* Obtaining data including amylase, CEA, cytology, surgical pathology, and 6 month clinical follow up after EUS FNA.

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CT Imaging of Acute Pancreatitis

CT Imaging of Acute Pancreatitis
Presentation by:Erin Rikard

Outline
* Definition
* Epidemiology
* Causal Factors
* Pathophysiology
* CT Evaluation and Findings – Normal and abnormal
* Complications
* Management
* Prognosis

Definition
Acute Pancreatitis - Inflammation of pancreas with potential for complete healing
Epidemiology
Causal Factors
Incidence
Cholelithiasis
Trauma/Surgery
Metabolic Disorders
Viral Infection
Pathophysiology
* Pancreatic autodigestion, with activated pancreatic enzymes escaping the ductal system and lysing tissue of pancreas and adjacent structures
* Lack of capsule facilitates spread
Normal CT Findings
Normal Anatomy by CT
* Pancreas arcing anteriorly over spine
* Head adjacent to duodenum
* Tail extending toward spleen
* Splenic vein posterior to body and tail
* Portal vein confluence immediately posterior & left of pancreatic neck

Normal Morphology by CT
Evaluation by CT
Evaluation of Acute Pancreatitis
* Contrast-enhanced CT is imaging modality of choice
* Oral and IV contrast differentiate pancreatic tissue from adjacent blood vessels and duodenum
Recommendations for Contrast-Enhanced CT
* Clinical diagnosis in doubt
* Severe clinical pancreatitis
* Ranson score > 3
* APACHE score > 8
* Failure to rapidly improve within 72 hours of beginning conservative medical therapy
* Initial improvement with later deterioration

Ranson Criteria
Abnormal CT Findings
* Peripancreatic inflammation
* Diffuse or focal pancreatic edema
* Poor definition and heterogeneity of gland
* Fluid collections
* Necrosis
* Thickening of pararenal fascia

Spectrum of Disease
* Mild Cases
* Severe Cases
Peripancreatic Inflammation/ Pancreatic Edema/Fluid Collections
Infection?
Necrosis
Complications
* Pancreatic Pseudocysts
* Abscess
* Hemorrhagic Pancreatitis
* Splenic Artery Pseudoaneurysm formation or rupture/ Splenic Venous Thrombosis

Pancreatic Pseudocyst
* Fluid collection surrounded by fibrous capsule but not lined by epithelium
* Occurs in 10% of cases
* Significant % will not resolve spontaneously
* Seen within pancreas and potential spaces with which gland is continuous (lesser sac and left pararenal space)
Abscess
Hemorrhagic Pancreatitis
Splenic Artery Pseudoaneurysm
Management
Prognosis
Reasons for Reduced Mortality
Resources

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Recurrent Idiopathic Pancreatitis

Recurrent Idiopathic Pancreatitis
Presentation lecture by:Rebecca Byers, MD
Primary Care Conference

Objectives
* Review the common clinical presentation of chronic pancreatitis.
* Describe the natural course of chronic pancreatitis.
* Discuss the various types of cystic lesions in the pancreas.
* Describe the diagnostic and treatment recommendations
* Disclaimer - I have not received any outside funding in regards to this presentation.

Clinical Cases
Hospitalization
* Stopped Lasix, Lisinopril, Cozaar.
* Renal arteriogram – normal.
* Echo – normal.
* +H. pylori – treated with 2 weeks Biaxin, Flagyl, Prevacid.
* Discharged on Amlodipine and Atenolol.
* BPs never high since.

GI Clinic Follow-up
* Diagnosis of Recurrent Idiopathic Pancreatitis and a mature pancreatic pseudocyst.
* Need to assess for structural abnormality
* Plan for repeat CT in 6 weeks and ERCP and/or endoscopic ultrasound.
* 8/4/03 – Abd CT without change. 4 non-specific pulm nodules, 6-7 mm. Endless f/u.

Surgical Consult
* Diagnosis of acute relapsing pancreatitis.
* Recommendation for resective drainage operation and definitive treatment.

ERPC

* Impression: (1)Recurrent pancreatitis (2) Improved pancreatogram with diffuse pancreatic ductal irregularities less prominent on this exam (3) No definite pancreatic duct stricture(s) visualized (4) s/p 5 mm pancreatic sphincterotomy with prompt drainage of contrast.

Endoscopic Ultrasound
* Impression: 1) Pancreatic tail solid-cystic lesion 2) FNA consistent with a mucinous neoplasm.
* FNA Report - Cytologic Exam: Positive, compatible with a mucinous neoplasm.


Surgery
* Surg Path Report – Predominantly intracystic mucinous adenocarcinoma, with focal infiltrating adenocarcinoma, in a background of chronic pancreatitis.
* Surgical margins were negative for carcinoma.
* Ten out of ten resected lymph nodes were negative for carcinoma. Adrenal gland and spleen also negative for carcinoma.

Surgical Follow-up

* Dilemma – If there was no invasive cancer, her treatment would now be complete; the finding of invasive cancer, along with some previously elevated tumor makers and pulmonary nodules, are concerning.
* Plan – redo all scans and serum markers, discuss at hepatobiliary conference, refer to medical oncologists.

Chronic Pancreatitis
* Chronic pancreatitis is an inflammatory condition that results in permanent structural changes in the pancreas which lead to impairment of exocrine and endocrine function.
* Can be asymptomatic over long periods of time, or can present as recurrent postprandial epigastric pain.

Clinical Features
* The two primary clinical manifestations are abdominal pain and pancreatic insufficiency.
* Pain is typically epigastric, often radiates to the back, often worse 15 to 30 minutes after eating, as the condition progresses, the pain tends to become more continuous.
* Problems digesting food/absorption, fat malabsorption, glucose intolerance/diabetes.
Etiology 1
Etiology 2
Pathogenesis
Diagnosis 1
Diagnosis 2
Complications
* Pseudocysts (10% of patients)
* Mechanical obstruction of the duodenum and common bile duct
* Pancreatic ascites
* Pleural effusion
* Splenic vein thrombosis with portal hypertension
* Pseudoaneurysm formation (e.g., splenic artery)

Cystic Lesions of the Pancreas
* Retention cysts
* Pseudocysts
* Cystic neoplasms.

Pseudocysts

* Result of pancreatic inflammation and necrosis.
* Single or multiple, small or large, located either in or outside of the pancreas.
* Most communicate with pancreatic ductal system, high concentrations of enzymes.
* Walls formed by adjacent structures; fibrous lining; lack an epithelial lining seen in true cystic lesions.

Cystic Neoplasms
* Mucinous cystadenoma/cystadenocarcinoma
* Mucinous duct ectasia (intraductal papillary mucinous neopplasm)
* Serous cystadenoma
* Papillary cystic neoplasm

Mucinous cystadenoma
* Most common cystic neoplasm.
* Typically in middle-aged women.
* Usually a mass lesion composed of one or more macrocystic spaces lined by mucous-secreting cells.
* Most are malignant at time of diagnosis. High potential for malignant change.

Management
Uncertain Etiology
References

Recurrent Idiopathic Pancreatitis.ppt

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