Endoscopic Resolution of Pseudocyst Infection

Rodrigo Azevedo Rodrigues, Lucianna Pereira da Motta Pires Correia,
Maria Rachel da Silveira Rohr, Frank Shigueo Nakao, Marcus Melo Martins dos Santos,
Angelo Paulo Ferrari, Ermelindo Della Libera
Division of Gastroenterology, Federal University of São Paulo. São Paulo, Brazil
ABSTRACT
Context Endoscopic therapy has recently
gained importance as an option for the
treatment of pancreatic necrosis. We report a
case of transgastric endoscopic resolution of
pseudocyst infection and necrosis as a
complication of endoscopic pseudocyst
drainage.
Case report The patient underwent several
sessions of endoscopic removal of debris and
necrotic material, intercalated with daily
lavage and aspiration through a nasocystic
tube.
Conclusions At the present time, fourteen
months after pancreatic pseudocyst secondary
infection, the patient remains asymptomatic
with no radiographic signs of pseudocyst
recurrence. Transmural endoscopic therapy
followed by continuous drainage and
necrosectomy is a reasonable option for
treating the pancreatic pseudocyst secondary
infection.
INTRODUCTION
Symptomatic pancreatic pseudocysts typically
present with abdominal pain, a palpable
epigastric mass and, occasionally, with
jaundice or gastric outlet obstruction.
Evidence of pancreatitis, a diameter greater
than 6 cm, multiplicity of pseudocysts and
thickening of the pseudocyst wall are
associated with a persistent course, which
occurs in up to 50% of cases, requiring
therapy [1]. Although surgery has been
considered the treatment of choice for this
complication, endoscopic therapy alone
achieves good results in more than two-thirds
of patients [2, 3, 4, 5, 6, 7]. Endoscopic
drainage can be performed through the gastric
or duodenal walls (transmural) or via the
pancreatic duct (transpapillary) [7, 8, 9].
Initially described for the treatment of simple
peripancreatic collections, the endoscopic
approach has recently gained importance as
an option for the treatment of pancreatic
necrosis [10, 11]. We report a case of
transgastric endoscopic resolution of
pseudocyst infection and necrosis as a
complication of endoscopic pseudocyst
drainage.
CASE REPORT
A 69-year-old man presented with a history of
upper abdominal pain and jaundice of 1-
month duration. The patient had a history of
elevated alcohol intake with a previous
diagnosis of chronic pancreatitis and liver
disease. Physical examination revealed
several stigmata of cirrhosis, a few ascites and
a well-defined abdominal mass of 10 cm or
more with a cystic consistency. One year
before admission, the patient presented with
acute pancreatitis complicated by an

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asymptomatic pseudocyst with no criteria for
drainage.
Initial laboratory evaluation showed the
following values: hemoglobin 8.6 g/dL
(reference range: 12.5-16.0 g/dL); hematocrit
26.8% (reference range: 39-45%); white
blood cells 7.6 x103/μL (reference range: 1.5-
7.5 x103/μL); neutrophils 62% (reference
range: 40-75%) and lymphocyte 21%
(reference range: 20-50%); platelet 281
x103/μL (reference range: 120-400 x103/μL);
random plasma glucose 207 mg/dL (reference
range: 80-110 mg/dL); creatinine 1.4 mg/dL
(reference range: 0.3-1.2 mg/dL); calcium 8.0
mmol/dL (reference range: 7.5-9.0 mmol/dL);
albumin 3.6 g/dL (reference range: 3.0-5.5
g/dL); serum AST 242 IU/L (reference range:
0-38 IU/L); serum ALT 318 IU/L (reference
range: 0-38 IU/L); total bilirubin 3.2 mg/dL
(reference range: 02-1.0 mg/dL); direct
bilirubin 2.3 mg/dL (reference range: 0.1-0.4
mg/dL); amylase 42 IU/L (references range:
0-160 IU/L) and lipase 180 IU/L (reference
range: 0-160 IU/L). The ascitic fluid was
turbid-yellow with a total cell count of
295/μL (40% lymphocyte), amylase 7.0 IU/L,
albumin 0.6 g/dL, total protein 1.4 g/dL and
negative for malignant cells. A chest
radiography was unremarkable. A CT scan
revealed an 18 cm thin-walled low-
attenuation cystic mass at the pancreatic
region associated with compression of the
posterior gastric wall (Figure 1). There was
no biliary tract dilation. Esophagogastro-
duodenoscopy showed three medium size
esophageal varices with no red-spots and an
extrinsic compression at the posterior gastric
wall. Endoscopic ultrasound confirmed
gastric compression and showed no major
vascular interposition. ERCP was performed
and revealed a distal benign biliary stenosis
easily trespassed with a plastic 10 Fr stent.
Brush cytology was unremarkable.
Pancreatography was not feasible at that time.
Endoscopic transgastric pseudocyst drainage
was planned. After prophylactic antibiotic
therapy, the posterior gastric wall was
punctured with a needle-knife catheter.
Balloon dilation of the puncture site was
performed. A large amount of brownish fluid
with no debris spurted out of the cyst and
three plastic straight stents (two of 10 Fr and
one of 7 Fr) were placed at the gastrocystic
window. The amylase level of the cystic fluid
was 3,950 IU/L. The patient was discharged
and placed on antibiotic therapy after prompt
remission of jaundice and pain. He was
asymptomatic one week later.
Twenty-five days after pseudocyst drainage,
the patient was readmitted with fever and
abdominal pain. A blood sample analysis
showed evidence of acute infection with no
Figure 1. Computerized tomography of the abdomen
revealed an intra-abdominal pseudocyst (18 cm)
associated with compression of the posterior gastric
wall.
Figure 2. Twenty-five days after pseudocyst drainage,
computerized tomography showed reduction of the cyst
size with air, heterogeneous material and migration of
the plastic stent into the cystic cavity.

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signs of cholangitis: white blood cells 5.6
x103/μL; 47% segmented neutrophils; 6%
band forms; 1% myelocytes; creatinine 0.9
mg/dL; albumin 2.2 g/dL; serum AST 29
IU/L; serum ALT 14 IU/L; total bilirubin 1.3
mg/dL; direct bilirubin 0.8 mg/dL; amylase
23 IU/L. The ascitic fluid, as well as, chest
radiography, urine sample and cultures were
unremarkable, indicating that the pseudocyst
was the source of infection. A new CT scan
revealed reduction of the cyst size (8x5 cm)
with air, heterogeneous material and two
plastic stents which had migrated into the
cystic cavity (Figure 2). Esophagogastro-
duodenoscopy showed a narrowed gastro-
cystic window with one occluded stent which
was removed. Balloon dilation (12 mm) of the
cystogastrostomy was performed. A large
amount of necrosis and pus, and the migrated
stents were seen endoscopically. The stents
were removed with a regular foreign-body
forceps and abundant lavage with saline
solution and suction was performed through
the gastroscope (Figure 3). Solid material was
gently removed with a polypectomy snare. A
nasocystic tube was placed into the cavity for
further lavage and aspiration. The patient
underwent four other similar procedures in a
3-day interval basis intercalated with a daily
1,000 to 2,000 mL lavage and aspiration
through the nasocystic tube. Antibiotics were
given. After the fifth endoscopic
necrosectomy, a CT scan showed a smaller
cystic lesion 5 cm in diameter and no solid
material in the cavity. Fourteen days after the
first necrosectomy, the nasocystic tube was
removed and three pigtail transgastric stents
were placed. The patient presented no signs of
infection and the leucocyte count was normal.
The patient was discharged and was followed
up as an outpatient. Another ERCP was
performed one week later. The biliary stent
was replaced and a second brush cytology
was negative for malignancy. At this time, a
pancreatography was carried out showing
complete disruption of the distal pancreatic
duct with no identification of its proximal
segment. Only two months after the first
necrosectomy, a CT scan showed no
collection on the pancreatic topography. The
pigtail and biliary stents were removed. At the
present time, fourteen months after pancreatic
pseudocyst secondary infection, the patient
remains asymptomatic with no radiographic
signs of pseudocyst recurrence.
DISCUSSION
Endoscopic therapy has played an increasing
role in the treatment of pancreatic
pseudocysts since it was first reported two
decades ago [6]. Surgical therapy is
associated with high rates of morbidity (15%)
and a mortality rate of up to 5%. Percutaneous
drainage is considered a temporary option
because of its high rate of recurrence (up to
70%), morbidity (up to 30%) and mortality
(up to 10%) [5]. Although less invasive than
other strategies, endoscopic therapy is not free
of complications. Bleeding at the puncture
site is usually mild but controlled during the
endoscopic procedure and rarely requires
surgical intervention [5, 12]. Perforation of
the peritoneal cavity is uncommon and
usually responds well to conservative
treatment [5]. This complication tends to be
less frequent with the ready availability of
EUS in most referral centers. EUS inspection
of the puncture site rules out the presence of
underlying major vessels. It is now considered
the standard of care for endoscopic pancreatic
pseudocyst decompression [8, 13].
Pseudocyst infection is the most common
complication [13] and may be associated with
stent migration or clogging. In these cases,
patients are usually referred to surgery unless
they are unfit for a surgical procedure.
Although most authors recommend double
Figure 3. Endoscopic aspect of the cystic cavity. a.
Necrosis, purulent collection, and migrated stent. b.
After aspiration and the repeated removal of solid
material.

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pigtail stents to be used for transmural
drainage [10, 13, 14], some series of
pancreatic pseudocyst drainage have shown
low rates of straight stent migration [5, 12].
Until now, no comparative study has been
published as to whether straight or pigtail
stents should be used for this purpose. A
pancreatography is advisable when pancreatic
pseudocyst therapy is considered. If a
disrupted duct is found, or when it cannot be
‘bridged’ by a stent, some authors believe that
endoscopic therapy should be discouraged
[15]. In this case, we were unable to access
the pancreatic duct during the first ERCP.
Endoscopic management of pancreatic
pseudocysts includes technically demanding
procedures and experienced hands [16].
Anyone who considers carrying out this
procedure must be able to manage eventual
complications. In the present case, the
migration of two straight stents and the
clogging of one transgastric stent were
probably the leading cause of pancreatic
pseudocyst infection and necrosis since the
patient had not had a recent episode of acute
pancreatitis. Transmural endoscopic therapy
followed by continuous drainage and
necrosectomy was a reasonable option to treat
this complication since this patient was not a
good candidate for surgery. Endoscopic
necrosectomy is gaining acceptance in the
treatment of primary organized pancreatic
necrosis [10, 16] and should also be
considered as an initial approach for the
resolution of secondary infection.
Received January 30th, 2008 - Accepted April,
24th, 2008
Keywords
Debridement;
Pancreatic
Pseudocyst; Pancreatitis, Chronic
Conflict of interest All authors confirm that
there are no potential conflicts of interest.
Correspondence
Rodrigo Azevedo Rodrigues
Rua Gomes de Carvalho, 100 casa 07
Vila Olímpia
São Paulo, SP
CEP 045 47 001
Brazil
Phone: +55-11.3849.9733
Fax: +55-11.5576.4050
E-mail: rodrigo.ar@terra.com.br
Document URL: http://www.joplink.net/prev/200807/11.html
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