Walled off Pancreatic Fluid Collections in Adults

Introduction:

Pancrease is situated behind the stomach and produces digestive enzymes. Inflammation of the pancreas is called pancreatitis. Pancreatitis is characterized as acute and chronic pancreatitis. Fluid accumulations are a complication of pancreatitis and result from pancreatic injury.

What Is Walled Pancreatic Fluid Collection (PFC)?

There are many complications of pancreatitis. One such complication is a walled-off pancreatic collection which is a chronic type.

Pancreatic fluid collections can be divided into two types based on their occurrence after pancreatitis.

1. Acute Collections - A fluid collection that occurs within four weeks after a pancreatitis episode is termed as an acute collection. They are subdivided into the following.

• Acute Peripancreatic Fluid Collections (APFC) - Fluid collection in a circumscribed wall without involving necrotic (dead) tissue.

• Acute Necrotic Collections (ANC) - Fluid collections in or around the pancreas without any well-defined wall and the presence of necrotic tissue are called acute necrotic collections. They are seen as an early complication of acute pancreatitis.

2. Chronic Collections - A pancreatic fluid collection that progresses after four weeks of pancreatitis episode are categorized as a chronic collection. They are subdivided into the following.

• Pseudocysts - Pancreatic pseudocyst refers to developed, encapsulated, walled-off PFCs that show little to no necrosis (death to an injury, chemicals, or radiation to the body tissues), which are more frequently associated with chronic pancreatitis but less frequently with acute pancreatitis. Inflammation and subsequent injury to the pancreatic ducts, which result in leakage and buildup of pancreatic fluid, are the causes of pancreatic pseudocysts.

• Walled-off Pancreatic Necrosis - Walled PFCs with necrosis, also called a pancreatic abscess, are mature, enclosed collections of dead tissue in or around the liver that are frequently connected to acute pancreatitis necrosis. It is a delayed complication of pancreatitis. Individuals with this condition should undergo long-term treatment as there are complications of infections, and oral intake resistance, which can be lethal.

• Inclusion Cysts - Inclusion cysts are rarely present and can resemble cancerous tumors. They are harmless and do not need to be removed. They are considered for treatment based on the final diagnosis and outcomes of leaving behind the inclusion cysts.

• Cystic Neoplasm - Cystic neoplasms are fluid-filled sacs present within the pancreas. They tend to grow slowly and must be checked to determine whether they are harmless. There are many cystic neoplasms, like serous, mucinous cystadenoma, and so on. They can be present as a solitary tumor, or a group of cysts can be present together.

What Are the Causes of Walled-off Pancreatic Fluid Collection?

• Acute Pancreatitis - It is a condition where the pancreas becomes inflamed over a short period. Acute pancreatitis is caused due to alcohol consumption or gallstone formation.

• Chronic Pancreatitis - It is a progressive disorder that leads to the destruction of the pancreas. Blockage in the pancreatic duct, the presence of gallstones, and hereditary diseases are the causes of chronic pancreatitis.

• Pancreatic Injury - Injuries to the pancreas can occur due to road traffic accidents or penetrating injuries like knife stabs, gunshots, etc.

What Are the Symptoms of Walled-off Pancreatic Fluid Collection?

Although most fluid collections are minor and asymptomatic, major fluid collections can induce symptoms such as:

• Weight loss.

• Fevers.

• Abdominal pain.

• Indigestion.

• Vomiting.

• Swollen belly.

How Is Walled of Pancreatic Fluid Collection Diagnosed?

• CT (Computed Tomography) Scan - It is a diagnostic method that combines X-rays and computer technology to visualize the conditions inside the body. It is a painless process and helps determine the severity of the condition.

• MRI (Magnetic Resonance Imaging) - It is a diagnostic method similar to a CT scan. Newer innovations and techniques in MRI provide an extra advantage in acute pancreatitis. It helps to evaluate the fluid contents for the presence of any solid tissue debris. In addition, it is a painless procedure.

• Endoscopic Ultrasound - Endoscopic ultrasonograph, assess the collection of the pancreatic fluid. During this treatment, an endoscope is inserted through the mouth while the patient is under anesthesia, allowing a specialist to accurately assess the cyst using an ultrasound instrument. Additionally, the gadget enables testing of the fluid collected, which is frequently useful for identifying the reason. Several blood and fluid tests can be useful in figuring out what is causing the fluid collection.

What Are the Complications of Pancreatic Fluid Collections?

Pancreatic fluid collection if left untreated, can lead to complications like -

• Infection.

• Hemorrhage (blood escapes from a ruptured blood vessel).

• Pain.

• Biliary obstruction (compressing the bile duct because of pancreatitis may block the bile juice from the liver to the small intestine).

• Fistula formation (a connection between two different organs or an organ and the external environment).

• Bowel obstruction (obstruction in the digestive system).

• Recurrent pancreatitis (re-occurrence of inflammation of the pancreas)

• Death.

What Is the Treatment for Pancreatic Fluid Collections in Adults?

Pancreatic fluid collection, a complication of pancreatitis, can increase risk when food intake is normal. And hence, patients are kept on nil per mouth (no food is consumed from the mouth).

Supportive Treatment 

• It is performed parallelly by maintaining blood pressure, volume, and body vitals.

• Routine antibiotic administration as patients are bacteremic (infected with bacteria).

• The antibiotic choice depends on the degree of infections and the type of bacteria.

• Fluids are also administered.

• The first step in management is maintaining nutritional status, done by enteral feeding.

Enteral Feeding 

• Feeding the patient with fluids using tubes connecting directly to the digestive system.

• Formulations of the fluids include standard forms, elemental forms, semi elemental forms.

• It is of two types, namely:

1. Early Enteral Feeding - Feeding within 48 hours of admission of the patient.

2. Late Enteral Feeding - Enteral feeding after 48 hours of patient admission.

However, early feeding has shown more positive outcomes than late enteral feeding.

Surgical Resection or Drainage 

Based on the presence of symptoms and infection complications, proper fluid drainage is recommended.

• Surgical Drainage - It is a process in which a connection between the cyst and the stomach is created; this process is called surgical cystogastrostomy.

• Percutaneous Drainage - Placement of a drainage catheter into the fluid-collected cyst using CT (computed tomography) scans or ultrasound.

• Conventional Transmural Drainage - It is a process that uses endoscopy to dilate the passage of the cyst, placing a stent and facilitating the drainage.

• Fully-Covered Self-Expanding Metal Stents (FCSEMS) - They provide a large lumen during drainage and prevent occlusion of the same. They are also advantageous as they require short procedure time.

• Plastic Stents - Except for the cost difference, no significant change in the outcome has been noted using plastic stents compared to metal stents.

Maintaining nutritional status and decreasing the infection through drainage or surgical resection is the main basis for treating walled-off pancreatic fluid accumulation.

Conclusion:

Pancreatic fluid accumulations are very common, and most never cause serious health problems. However, it is essential that they receive a proper diagnosis and that any problematic symptoms are addressed. Therefore, specialists like gastroenterologists, pancreatic surgeons, or medical oncologists should always be consulted when a pancreatic fluid accumulation is seen.