[Non-surgical therapy of pancreatitis complications (pseudocyst, abscesses, stenoses)]

Acute and chronic pseudocysts differ. Chronic pseudocysts develop during the evolution of chronic pancreatitis unrelated to a specific bout of clinically recognizable acute pancreatitis. Acute pseudocysts arise in conjunction with an episode of acute pancreatitis. Whereas until recently surgical therapy has been the standard treatment for acute (or chronic) pancreatic pseudocysts, a range of nonsurgical options has been developed. The most important nonsurgical treatment of all is to watch and wait. Pseudocysts following acute pancreatitis should be observed when they are truly asymptomatic and less than or equal to 6 cm in diameter and left alone if not increasing in size. Only if after a six-week observation period pancreatic pseudocysts increase in diameter and become symptomatic, percutaneous needle aspiration, catheter drainage or an endoscopic drainage procedure (cystogastrostomy/cystoduodenostomy) or ultimately operative drainage procedure should be considered. Antibiotic therapy should be considered for all patients presenting with pancreatic necrosis. They should be treated with drugs administered intravenously at the maximum recommended dose as early as possible after onset of symptoms, continued throughout at least the first two weeks of the disease. Moreover, they should be treated alone and/or in combination with antibiotics that are active against gram-negative organisms of intestinal origin, commonly isolated in necrotic tissue, pseudocysts and infected pancreatic abscesses, and that are capable of penetrating into the pancreatic juice and necrotic tissue (e.g. mezlocillin, cephalosporin, metronidazole). Removal of pancreatic stones and pancreatic stenosis by endoscopic procedures in the treatment of pain in patients with chronic pancreatitis is still not an established and generally accepted treatment. Controlled trials to validate stenting and ESWL in chronic pancreatitis are needed.