Synopsis
Classify a pancreatic collection by its contents and wall, identify complications that justify intervention, and explain the anatomical and follow-up decisions around drainage.
- A pseudocyst is predominantly fluid within a defined inflammatory wall, with essentially no solid necrotic debris.
- Walled-off necrosis contains non-viable tissue as well as fluid within an organised wall; it can appear deceptively homogeneous on CT.
- Before a wall forms, distinguish early fluid-only from necrotic collections. Maturation commonly takes about four weeks, but neither that interval nor size alone determines intervention; symptoms, complications and safe anatomy do.
Key red flags
Haematemesis, melaena, new blood in a drain or a sudden haemoglobin fall.
Fever with worsening physiology, confusion or reduced urine output.
Progressive vomiting, inability to maintain nutrition or a rapidly worsening abdomen.
Gastric compression can produce persistent vomiting and nutritional failure; biliary compression may cause jaundice. Infection is judged from clinical deterioration and appropriate imaging or microbiology. Bleeding may be internal before external signs appear. These findings change urgency and may require radiological or surgical assessment before an endoscopic drainage procedure is attempted.
Investigation priorities
Define the collection, surrounding organs, necrosis and important vascular relationships.
Management branches
A 51-year-old woman returns seven weeks after necrotizing pancreatitis with daily vomiting, early satiety and a 5 kg weight loss; CT calls an 8 cm retrogastric space a probable pseudocyst.
- She is afebrile and haemodynamically stable, but cannot maintain oral nutrition. MRI shows a mature wall with extensive internal debris and compression of the stomach: this is walled-off necrosis. The indication for intervention is sustained gastric obstruction and nutritional failure, rather than the 8 cm diameter. The team provides enteral nutritional support while arranging pancreatic-centre assessment.
- EUS confirms a suitable internal route without an intervening vessel. The specialist team performs endoscopic drainage and records the stent type, responsible endoscopist and planned interval imaging and device review. Over the next 72 hours, vomiting stops and she tolerates increasing food intake; no immediate necrosectomy is required because she is improving.