Clin Endosc.  2017 Jan;50(1):76-80. 10.5946/ce.2016.089.

Mediastinal Pancreatic Pseudocysts

• DÄ…bkowski K
• BiaÅ‚ek A
• Kukla M
• Wójcik J
• SmereczyÅ„ski A
• KoÅ‚aczyk
• Grodzki T
• StarzyÅ„ska T

• KMID: 2383494
• DOI: http://doi.org/10.5946/ce.2016.089

Abstract

Mediastinal pseudocysts are a rare complication of acute pancreatitis. Lack of uniform treatment standards makes the management of this condition a clinical challenge. We report the case of a 43-year-old patient who presented with a left pleural effusion. Pleural fluid revealed a high amylase concentration consistent with a pancreaticopleural fistula. Endoscopic retrograde cholangiopancreatography (ERCP) revealed a disruption of the pancreatic duct with free outflow of contrast medium into the thoracic cavity. A pancreatic stent was placed. The second day after the ERCP, the patient developed septic shock and was admitted to the intensive care unit. Computed tomography (CT) revealed mediastinal pseudocysts and bilateral pleural effusions. After bilateral drainage of the pleural cavities, the patient improved clinically, and a follow-up CT scan showed that the fluid collection and pseudocysts had resolved. We discuss the optimal strategies for diagnosing and treating patients with pancreatic thoracic pseudocysts and fistulas, as well as review the management of these conditions.

Keyword

Acute pancreatitis; Cholangiopancreatography, endoscopic retrograde; Mediastinal pseudocysts

MeSH Terms

Adult
Amylases
Cholangiopancreatography, Endoscopic Retrograde
Clothing
Drainage
Fistula
Follow-Up Studies
Humans
Intensive Care Units
Pancreatic Ducts
Pancreatic Pseudocyst*
Pancreatitis
Pleural Cavity
Pleural Effusion
Shock, Septic
Stents
Thoracic Cavity
Tomography, X-Ray Computed
Amylases

Figure

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  Fig. 1. Chest radiograph demonstrating fluid in the left pleural cavity.

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  Fig. 2. Endoscopic retrograde cholangiopancreatography showing free outflow of the contrast medium from the proximal portion of the pancreatic tail to the mediastinum (the arrow points to the “leakage”).

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  Fig. 3. Endoscopic retrograde cholangiopancreatography showing the location of the stent in the pancreatic duct. The stent is placed distally to the fistula, as close as possible to the leakage point.

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  Fig. 4. (A, B) Abdominal ultrasound depicting pseudocysts in the posterior mediastinum.

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  Fig. 5. Computed tomography scan of the chest showing mediastinal pseudocysts and pleural fluid.

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  Fig. 6. Chest radiograph showing fluid resolution after pleural fluid drainage.

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  Fig. 7. Resolution of pseudocysts on the 12-month follow-up computed tomography scan.

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