Continuing Medical Education Questions: April 2018: ACG Clinical Guideline: Diagnosis and Management of Pancreatic Cysts

Abstract

LEARNING OBJECTIVES After this activity, the participant will identify patients appropriate for pancreatic cyst surveillance and choose pancreatic cyst surveillance intervals based on imaging characteristics. QUESTIONS: 1. A thin 68-year-old woman underwent an abdominal ultrasound to evaluate kidney size during an evaluation of her recently diagnosed chronic kidney disease. A pancreatic tail cyst was incidentally identified. She reports no fever, abdominal pain, nausea, vomiting, or weight loss. Her past medical history is notable for gastroesophageal reflux disease. Her only medication is oral esomeprozole 40 mg daily as needed. There is no history of pancreatitis or significant alcohol consumption. On exam, she is afebrile, blood pressure is 108/70 mm Hg, pulse rate is 84/min, and respirations are 14/min. Her abdomen is soft and nontender. The remainder of her exam is normal. Abdominal ultrasound revealed normal kidneys without hydronephrosis. The pancreas was notable for a 1.8 cm pancreatic tailcyst. No further characteristics of the cyst are reported. Which of the following imaging modalities is recommended to further characterize this pancreatic cyst? A. Computed tomography (CT) of the abdomen with intravenous and oral contrast B. Endoscopic ultrasound with fine needle aspiration (EUS-FNA) C. Magnetic resonance imaging (MRI) with magnetic resonance cholangiopancreatography (MRCP) D. Positron emission tomography/computed tomography (PET/CT) 2. A 76-year-old woman with a history of lower extremity claudication is referred for further evaluation of a pancreatic cyst identified on a recent CT angiogram. She has no significant gastrointestinal symptoms. She has multiple medical problems including insulin-dependent diabetes mellitus type II with subsequent end-stage renal disease, coronary artery disease requiring 2 coronary artery stents following a myocardial infarction, peripheral vascular disease, and a transient ischemic attack 6 months ago. She quit cigarettes 5 years ago and does not drink alcohol. On physical exam, she appears chronically ill, with a blood pressure of 148/96 mm Hg. Her abdominal exam is normal. Her peripheral pulses are weak. Laboratory testing reveals hemoglobin of 10.1 g/dL, alkaline phosphatase 125 U/L, and total bilirubin 0.8 mg/dL. Recent abdominal CT reveals a 2.1-cm pancreatic body cyst directly adjacent to a mildly dilated 4-mm pancreatic duct. There is no mention of mural nodules, cyst septation, or chronic pancreatitis. The splenic artery is densely calcified as are many other intra-abdominal arteries. Which of the following is the best next step in evaluation of this pancreatic cyst? A. MRI with MRCP B. CT of the abdomen with intravenous and oral contrast C. Referral to multidisciplinary pancreatic group D. No further evaluation is required 3. Five years ago, a 72-year-old woman was found to have a 1.8-cm pancreatic head cyst on chest CT imaging performed for lung cancer screening due to smoking history. Based on these findings, annual MRI scanning was performed for 5 years and there has been no subsequent change in cyst size or characteristics. She has no current gastrointestinal or systemic symptoms. She no longer smokes and does not drink alcohol. On physical exam, her blood pressure of 118/72 mm Hg. Her physical examination, laboratory values, and Ca 19-9 are normal. The most recent follow-up abdominal MRI reveals a 1.8-cm pancreatic head cyst. There is no evidence for mural nodularity and the pancreatic duct size is normal. There is no associated mass. Based on this guideline, which of the following would be the most appropriate recommendation for surveillance of this cyst? A. Repeat MRI with MRCP in 2 years. B. Repeat MRI with MRCP in 1 year. C. Discontinue pancreatic cyst surveillance as the cyst characteristics are unchanged. D. Order PET/CT and, if negative, discontinue surveillance.