Mediastinal pseudocyst clinically presenting as mechanical dysphagia and dyspnea in a case of acute-on-chronic pancreatitis

Reddy Ravikanth; Partha Sarathi Sarkar; Alok Kale

doi:10.4103/jcrsm.jcrsm_61_17

CASE REPORT

Year : 2018 | Volume : 4 | Issue : 1 | Page : 62-64

Mediastinal pseudocyst clinically presenting as mechanical dysphagia and dyspnea in a case of acute-on-chronic pancreatitis

Reddy Ravikanth, Partha Sarathi Sarkar, Alok Kale
Department of Radiology, St. John's Medical College, Bengaluru, Karnataka, India

Date of Submission	19-Oct-2017
Date of Acceptance	09-Jan-2018
Date of Web Publication	25-May-2018

Correspondence Address:
Reddy Ravikanth
Department of Radiology, St. John's Medical College, Bengaluru - 560 034, Karnataka
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jcrsm.jcrsm_61_17

Abstract

Pseudocyst is a common complication of acute pancreatitis. However, its extension into the mediastinum is a rare entity. Contrast-enhanced computed tomography has a very high sensitivity in providing the location and anatomical relation of the pseudocyst to the surrounding structures. Here, we present a rare case of pancreatic pseudocyst in the mediastinum presenting clinically with dysphagia and dyspnea.

Keywords: Acute pancreatitis, contrast-enhanced computed tomography, dysphagia, endoscopic cystogastrostomy, mediastinal pseudocyst

How to cite this article:
Ravikanth R, Sarkar PS, Kale A. Mediastinal pseudocyst clinically presenting as mechanical dysphagia and dyspnea in a case of acute-on-chronic pancreatitis. J Curr Res Sci Med 2018;4:62-4

How to cite this URL:
Ravikanth R, Sarkar PS, Kale A. Mediastinal pseudocyst clinically presenting as mechanical dysphagia and dyspnea in a case of acute-on-chronic pancreatitis. J Curr Res Sci Med [serial online] 2018 [cited 2020 Oct 29];4:62-4. Available from: https://www.jcrsmed.org/text.asp?2018/4/1/62/233199

Introduction

Pseudocysts associated with chronic pancreatitis are generally intrapancreatic. Thoracopancreatic fistula is a rare complication of pancreatitis that manifests as a fistulous communication between pancreas and chest. Thoracopancreatic fistulas are divided into four types based on the termination site of the fistula: pancreaticopleural, mediastinal pseudocyst, pancreaticobronchial, and pancreaticopericardial.^[1] Here, we present a rare case of a mediastinal pancreatic pseudocyst in a patient with acute-on-chronic pancreatitis.

Case Report

A 45-year-old male with a history of chronic alcohol consumption presented to the emergency department with a history of epigastric pain and dysphagia for 5 weeks, worsened in the last 1 week with associated dyspnea. On examination, the patient had tachycardia and severe epigastric tenderness with guarding. Serum amylase and lipase levels were investigated and found to be elevated, in the range of 946 and 4521 U/L, respectively. Subsequently, he was admitted in the Intensive Care Unit.

Imaging evaluation included a chest radiograph which revealed mediastinal air-fluid level [Figure 1] with bilateral costophrenic angle blunting. The stomach gas bubble was noted in its normal position below the left diaphragmatic crus. A penetrated supine radiograph of the chest was done next which revealed left-lateral displacement of the Ryle's tube which is suggestive of extrinsic mass effect on the esophagus [Figure 2]. A contrast-enhanced multidetector computed tomography (CT) scan of the thorax was done which revealed a thin-walled lesion with fluid attenuation in the posterior mediastinum extending superiorly up to the carina and inferiorly up to the pancreatic tail through the esophageal hiatus of the diaphragm. There is mass effect on the left main bronchus, left atrium, and pulmonary veins. The esophagus is displaced laterally to the left with resultant luminal narrowing. Hypodense pancreatic parenchymal foci were noted within the tail region with peripancreatic inflammatory changes. Bilateral pleural effusions were noted with subsegmental atelectasis of posterobasal segments of bilateral lungs [Figure 3] and [Figure 4].

Figure 1: Frontal chest radiograph showing mediastinal air-fluid level (arrow) with bilateral costophrenic angle blunting. The stomach gas bubble was noted in its normal position below the left diaphragmatic crus

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Figure 2: Penetrated supine chest radiograph showing left-lateral displacement of the Ryle's tube which is suggestive of extrinsic mass effect on the esophagus (arrows)

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Figure 3: (a) Axial contrast-enhanced computed tomography (CECT) scan of the chest above the level of the pseudocyst showing the central location of the esophagus (arrow), (b) Axial CECT showing posterior mediastinal lesion (star) with fluid attenuation causing lateral displacement of the esophagus (arrow), (c) Axial section of CECT scan at the level of diaphragmatic hiatus showing extension of the pseudocyst (star) into the mediastinum causing lateral displacement of the esophagus (arrow)

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Figure 4: Reformatted coronal image (a) and true coronal sections (b) of contrast-enhanced multidetector computed tomography scan of the chest showing collection (star) extending up to pancreatic tail (arrow)

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Endoscopic cystogastrostomy with drainage of the pseudocyst was done on the following day resulting in complete symptomatic relief, and follow-up imaging showed near-total resolution in cyst size [Figure 5].

Figure 5: Coronal (a) and axial (b) sections of contrast-enhanced computed tomography and contrast-enhanced multidetector computed tomography scan of the chest following endoscopic cystogastrostomy with drainage tube in situ(arrow) showing near-complete resolution of the posterior mediastinal pseudocyst (star)

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Discussion

Pancreatic pseudocyst is a well-known complication of acute pancreatitis (10%) and more commonly seen in chronic pancreatitis (30%–40%).^[2] Pseudocyst of the pancreas is a localized fluid collection that is rich in amylase and is surrounded by a wall of fibrous tissue. Pancreatic pseudocysts are seen in the peripancreatic region but can rarely be seen in atypical locations – liver, spleen, kidney, mediastinum, and pelvis causing challenges in diagnosis and management.

Contrast-enhanced CT has a very high sensitivity in providing the location and anatomical relation of the pseudocyst to the surrounding structures. CT shows a thin, cystic, low attenuated mass, the contents of which can be isoattenuating or hyperattenuating in relation to water, depending on the presence of hemorrhage or infection.

Pancreatic pseudocyst is a well-known complication of acute pancreatitis (10%) and more commonly seen in chronic pancreatitis (30%–40%).^[3] Enlarging pseudocyst of the pancreas dissects along the planes of least resistance and may extend into the thorax through the aortic hiatus, esophageal hiatus, or foramen of Morgagni.^[4] Pleural effusions are seen in the majority of mediastinal pseudocyst cases.^[5] Complications of a mediastinal pseudocyst can occur due to compression, invasion, or rupture of the pseudocyst into the surrounding structures, besides hemorrhage and infection. Retrocardiac compression leading to congestive cardiac failure has also been reported in literature. Mediastinal pseudocysts may also erode into the pericardial sac causing life-threatening cardiac tamponade and into the pleural space producing pleural effusion.^[6]

Drainage may be in the form of laparotomy, radiologically guided external drainage, or endoscopically guided internal drainage. Transcutaneous external drainage may be combined with CT-guided stent placement but has the risk of complications of bleeding, infection, and clogging of catheter and pancreatic fistula.^[7] Endoscopic internal drainage may be in the form of either ERCP with transpapillary duct drainage when there is a communication between pancreatic duct and mediastinal pseudocyst or may be in the form of transmural drainage using endoscopic ultrasound. Open surgical procedures such as cystogastrostomy, cystojejunostomy, pancreaticojejunostomy, and transdiaphragmatic cystojejunostomy with loop Roux-en-Y are reserved for complicated mediastinal pseudocysts such as infections, obstruction, rupture, or hemorrhage.^[8]

Conclusion

Mediastinal pseudocyst should be suspected in a patient clinically diagnosed to have pancreatitis with progressive dysphagia. Clinical presentation, raised serum amylase and lipase levels, and demonstration of mediastinal extension of the cyst on CT help in clinching the diagnosis of a mediastinal pseudocyst. Endoscopic cystogastrostomy with drainage of the pseudocyst is useful for symptomatic relief.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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