The Natural History and Management of Patients With Pancreatic Pseudocysts as a Complication of Acute Pancreatitis

Medicine, Pathology

Shearer, Michael George

University:University of Glasgow

关键词: Medicine, Pathology;   

Others  :  http://theses.gla.ac.uk/78380/1/11011447.pdf

来源: University of Glasgow

【 摘 要 】

In this thesis I have studied the natural course, outcome and management of patients who developed a pancreatic pseudocyst following an episode of acute pancreatitis. The clinical information for this work originated in 2 studies involving a total of 129 patients with a pseudocyst. This represents one of the largest reports of such patients in medical literature. One study was of 100 patients with a pseudocyst presenting to Glasgow Royal Infirmary, over a period of 23 years (1962 - 1984 ) (Chapter 3 ) (Imrie et al 1988 . Appendix 1). The second study was of 29 similar patients (Chapter 4) documented during a prospective trial of therapeutic peritoneal lavage in patients with severe acute pancreatitis recorded in Leeds, Bristol and Glasgow (1982 - 1984) (Corfield et al 1985, Mayer et al 1985. Appendix 1). Using the information derived from these studies, I have formulated an assessment system for predicting the likelihood of spontaneous resolution of a pseudocyst (Chapter 8). With the addition of results obtained from an analysis of percutaneous needle aspiration (Chapter 6) and analysis of acute phase reactant proteins within pseudocyst fluid (Chapter 7) I propose a new plan of management for patients with acute pancreatic pseudocysts. The important findings of this thesis are summarised as follows:- 1. The "waiting time" for conservative management of a pancreatic pseudocyst could safely be extended to 12 weeks. Bradley et al (1979) have suggested that a period of 6 weeks from the time of pseudocyst formation should be regarded as both the maximum time to wait for spontaneous resolution of a pseudocyst and the optimum time to consider some form of drainage procedure. A pseudocyst was drained surgically in 78 (%) of the 100 patients from Glasgow Royal Infirmary and resolved spontaneously in the other 22 (%). The median time from diagnosis to drainage by cystogastrostomy was 12 weeks (range 2 - 69 weeks). The median time to complete spontaneous resolution was also 12 weeks (range 2 - 104 weeks). Of the 29 patients from Leeds, Bristol and Glasgow surgical drainage was performed in 11 (38%) at a median time of 7 weeks (range 3-38 weeks) and spontaneous resolution occurred in 15 (52%) at a median time of 7 weeks (range 2-20 weeks). Bradley et al (1979) also found an increasing proportion of patients developed complications the greater the time a pseudocyst was left untreated. Only 6 (5%) of all 129 patients studied suffered complications as a result of an undrained pseudocyst. Based on the above results I suggest that 6 weeks is too short a period and 12 weeks is a more appropriate time to wait for spontaneous resolution to occur provided the is repeatedly assessed by clinical examination and ultrasound scanning to confirm that the diameter of the pseudocyst is not increasing and that the clinical state of the clinical state of the patient is not deteriorating. 2. No single factor causing acute pancreatitis predisposes to pseudocyst formation. Of the 100 patients from Glasgow Royal Infirmary alcohol was the cause of acute pancreatitis in 59%, gallstones in 27% and the aetiology was idiopathic in 9%. In contrast, of the 29 patients from Leeds, Bristol and Glasgow alcohol was the aetiological factor in 23%, gallstones in 48% and it was idiopathic in 23 %. This distribution was very similar to that of a total of 418 patients with acute pancreatitis studied in the three cities (Chapter 4)(gallstones 54%: alcohol 20%: idiopathic 21%). This suggests that no single aetiological factor of acute pancreatitis is more likely to cause pseudocyst formation. 3. The aetiology of the preceding acute pancreatitis is an important factor in determining the outcome of patients with a pseudocyst. The mortality amongst patients from Glasgow Royal Infirmary with gallstone induced pancreatitis and pseudocyst formation was 22% significantly greater than that of patiens with alcohol induced disease (5% mortality. The majority of patients who died as a result of gallstone induced disease did so because of sepsis and/or haemorrhage. The implication from this is that, if possible, in order to decrease the possibility of infection, the biliary tract should be cleared of stones at the time of definitive pseudocyst surgery. 4. Spontaneous resolution of a pseudocyst can be predicted using a multi-factor assessment system. A pseudocyst resolved spontaneously in 22 (%) of the 100 Glasgow Royal Infirmary patients and 15 (52%) of those from Leeds, Bristol and Glasgow. Differences in clinical, laboratory and radiological findings in these patients were compared with those of patients whose pseudocyst needed drainage. The proportion of patients with a palpable abdominal mass was significantly greater in those who required surgery in both groups of patients. The results for the patients from Leeds, Bristol and Glasgow also showed a significantly higher proportion with abdominal distension and a leukocytosis (>10 x 10e9 cells/1) amongst those who underwent surgery.(Abstract shortened by ProQuest.).