Mediastinal Pancreatic Pseudocyst-A Case Report and Review of the Literature

Ruchi Gupta, MD; Juan C. Munoz, MD; Praveen Garg, MD; Ghania Masri, MD; Norris S. Nahman, Jr., MD; Louis R. Lambiase, MD

Disclosures

April 11, 2007

Case Report

A 67-year-old woman presented to the emergency department with a 3-month history of worsening chest pain and dyspnea. She also reported new-onset dysphagia, postprandial fullness, and a 10-pound weight loss. The chest pain was nonexertional in the retrosternal area and was more of a constant dull ache. She complained of dysphagia with solid foods such as steak for the previous 3 weeks. Her medical history was significant for gastritis, chronic obstructive pulmonary disease, and hypertension. Her medications included omeprazole, hydrochlorothiazide, and salbutamol and ipratropium bromide metered dose inhalers. A year previously, the patient had an attack of acute alcoholic pancreatitis after an alcohol binge for which she was hospitalized and discharged without any complications. At the time of discharge on that admission her amylase level was 88 mg/dL (normal, 28-100 mg/dL). She did not follow up with her primary care physician, continued to drink, and had occasional episodes of self-limiting pain for which she did not seek any treatment. At this admission, her vital signs included a blood pressure reading of128/80 mm Hg and heart rate of 90 beats per minute. She was afebrile, with 97% oxygen saturation on room air. In general, the patient was not in any acute distress. Cardiopulmonary examination was unremarkable. Her abdomen was soft, nontender with normal bowel sounds, and no organomegaly. Laboratory workup revealed a white blood cell count of 6700/cc, hematocrit of 36 g/dL, and platelet count of 250,000/cc. She had normal cardiac enzyme and electrolyte levels, and normal renal function panel results. The patient had an elevated amylase level of 149 mg/dL (normal, 28-100 mg/dL) and a normal lipase level at 35 mg/dL (normal, 0-60 mg/dL). Admission electrocardiogram revealed normal sinus rhythm without any changes suggestive of ischemia. Her liver enzyme levels were normal except for elevated aspartate aminotransferase of 72 mg/dL (normal, 14-33 mg/dL). Because angina was also a possibility, the patient underwent dobutamine stress echocardiography, which did not show any evidence of ischemia. Admission chest radiography revealed a retrocardiac opacity (Figure 1).

Figure 1.

Anteroposterior view of chest showing retrocardiac opacity (arrows).

Subsequent workup revealed a large echolucent area compressing the left atrium on the two-dimensional echocardiogram (Figure 2).

Figure 2.

Two-dimensional echocardiogram (apical 4-chamber view) showing compression of left atrium by an echolucent mass (arrow).

An upper gastrointestinal series that was performed for dysphagia was significant for compression of the distal esophagus by an extrinsic mass. An abdominal computed tomography (CT) scan showed a 19 × 12 cm hypodense cystic mass extending from the body of the pancreas into the thorax up to the subcarinal angle being posterior to the esophagus and anterior to the descending aorta. The cystic mass was compressing the distal esophagus, and possibly the cardiac chambers (Figure 3).

Figure 3.

CT scan showing mediastinal pseudocyst (PP) causing compression of esophagus (arrow).

Endoscopic retrograde cholangiopancreatography (ERCP) was performed, which showed normal ductal anatomy. There was no communication between the pancreatic duct and the pseudocyst on the ERCP. Because of the proximity to the major vessels and absence of a clear bulge inside the stomach or esophagus, endoscopic ultrasound (EUS)-guided transesophageal drainage of the mediastinal pseudocyst was performed through the lower third of the esophagus. Color Doppler was used before needle puncture to confirm the absence of significant vascular structures within the needle's path. Two passes were made with a 19-gauge needle via a transesophageal approach; 250 mL of serous amber fluid was removed. No drainage stent was left in place. The fluid had a very high amylase level (4980 mg/dL). The Gram stain and culture did not reveal any organisms. Tumor markers, CA19-9 and carcinoembryonic antigen, were within normal limits. She reported immediate improvement in her symptoms within a day after the procedure. The patient did have a 1-month and 3-month post-procedure follow-up in the gastroenterology outpatient clinic. She is asymptomatic and has gained 5 pounds since the drainage of the mediastinal pseudocyst.

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