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Mediastinal extension of a pancreatic pseudocyst
THE AMERICAN JOURNAL OF GASTROENTEROLOGY © 2000 by Am. Coll. of Gastroenterology Published by Elsevier Science Inc.
Vol. 95, No. 12, 2000 ISSN 0002-9270/00/$20.00 PII S0002-9270(00)02180-8
Mediastinal Extension of a Pancreatic Pseudocyst Edward A. Rose, M.D., M.S.A., F.A.A.F.P., Munawar Haider, M.D., F.R.C.S., Sung K. Yang, M.D., and A. J. Telmos, M.D., F.A.C.S. Department of Family Medicine; Department of Internal Medicine, Division of Gastroenterology; Department of Surgery, Division of General Surgery, Wayne State University, Detroit, Michigan
INTRODUCTION Pancreatitis is a relatively common condition. Pseudocysts can complicate some cases. The diagnosis of pancreatic pseudocysts has been greatly aided by ultrasonography, computed tomography (CT), and magnetic resonance imaging (MRI). Most pseudocysts are intra-abdominal, with extra-abdominal extension being uncommon. We report a case involving pancreatic pseudocyst that was found in an unusual location.
CASE REPORT A 48-yr-old male with a history of recurrent pancreatitis, alcoholism, and type 2 diabetes mellitus presented to the emergency room with a 5-day history of abdominal pain. The pain started after a bout of heavy alcohol intake. He described the pain as sharp and continuous, located in the epigastrium, with radiation to the back in the interscapular region. Bending forward relieved the pain. Physical examination was noncontributory. Laboratory studies revealed a normal blood count. Plasma sodium was low at 129 mmol/L, with a normal potassium (4.4 mmol/L). Serum amylase and lipase were 37 U/L and 128 U/L, respectively. An ultrasound revealed increased echogenicity of the head of the pancreas with possible calcifications, as well as the presence of gallstones along with a small stone in the common bile duct. An endoscopic retrograde cholangiopancreatography (ERCP) procedure was planned, with the intent of sphincterotomy and removal of the common bile duct stone. At ERCP (Fig. 1) no stone was visualized after injection of the contrast agent. However, contrast did fill what appeared to be a pancreatic pseudocyst that extended into the mediastinum; this measured 3 ⫻ 10 cm in length. The endoscopist had the impression that the pseudocyst seemed to empty back into the fundus of the stomach. A CT scan performed immediately postprocedure (Fig. 2) confirmed the mediastinal extension of approximately 4 cm of the pancreatic pseudocyst but revealed no evidence of a fistula into the stomach. The patient was taken to the operating room the following day. At the time of surgery, the surgical team was unable to
identify the abdominal portion of the pseudocyst, confirming that the pseudocyst seen on ERCP was, in fact, the mediastinal pseudocyst seen on CT scan. The postoperative course was uneventful. One month postoperatively, the patient was asymptomatic. A follow-up CT scan was planned, but the patient has been lost to follow-up.
DISCUSSION Pancreatic pseudocysts are a recognized complication of both acute and chronic pancreatitis. Pseudocysts are said to occur in 16 –50% of cases of acute pancreatitis, and in 20 – 40% of cases of chronic pancreatitis (1). Seventy to eighty percent of pancreatic pseudocysts are said to be related to alcoholic pancreatitis, with the remainder being associated with gallstone pancreatitis, trauma, hyperlipidemia, or recent surgical operations or procedures (e.g., ERCP) (1).
Figure 1. ERCP showing pseudocyst opacified (C ⫽ pseudocyst, PD ⫽ pancreatic duct).
AJG – December, 2000
Mediastinal Extension of a Pancreatic Pseudocyst
3639
external drainage, and nonoperative radiographic and endoscopic drainage techniques have been described (1, 2). Because predominantly mediastinal pseudocysts are unsuitable for endoscopic decompression, and radiologic (percutaneous) access may be difficult or impossible, most symptomatic cases require surgical management. Because our patient was a candidate for cholecystectomy and had what appeared to be an extensive pancreatic pseudocyst, we opted for an open procedure that would allow not only the cholecystectomy, but also evaluation and possible surgical drainage of the pseudocyst. Postoperatively he did well, with resolution of all symptoms. Figure 2. CT scan showing section through lower chest (C ⫽ pseudocyst, ES ⫽ esophagus, DA ⫽ descending aorta, LA ⫽ left atrium).
A vast majority of pancreatic pseudocysts are located in the abdomen, retroperitoneally behind the pancreas. Less than 50 cases of mediastinal pancreatic pseudocysts have been reported in the English language literature (2–5). Such pseudocysts tend to be located in the posterior mediastinum, having extended through the aortic or esophageal hiatus (2, 5). The symptoms associated with mediastinal pancreatic pseudocysts tend to be nonspecific, as in the current case. Abdominal pain; nausea; vomiting; and chest, back, and shoulder pain have been reported (2). Dysphagia, pleural effusions (3), spontaneous esophageal fistulization (6), and even congestive heart failure (7) also have been reported. The management of mediastinal pancreatic pseudocysts is controversial and depends, in part, on their size. Small pseudocysts (⬍5 cm in diameter) (8) may resolve spontaneously over the course of several weeks and may be managed conservatively. Larger pseudocysts have a higher probability of complications, and are therefore more likely to require definitive therapy. Surgical resection, internal or
Reprint requests and correspondence: Edward A. Rose, M.D., Department of Family Medicine, 26454 Woodward Ave., Royal Oak, MI 48067-0919. Received June 17, 1998; accepted Mar. 25, 1999.
REFERENCES 1. Grace PA, Williamson RCN. Modern management of pancreatic pseudocysts. Br J Surg 1993;80:573– 81. 2. Gentry SE, Harris MA. Posterior mediastinal mass in a patient with chest pain. Chest 1995;107:1757–9. 3. Zeilender S, Turner MA, Gauser FL. Mediastinal pseudocyst associated with chronic pleural effusions. Chest 1990;97: 1014 – 6. 4. LeRoux BT, Kallichrum S, Shama DM. Mediastinal cysts and tumors. Curr Probl Surg 1984;21:1–76. 5. Casson AG, Inculet R. Pancreatic pseudocyst: An uncommon mediastinal mass. Chest 1990;98:717– 8. 6. Landrenau RJ, Johnson JA, Keenan RJ, et al. “Spontaneous” mediastinal pancreatic pseudocyst fistulization to the esophagus. Ann Thor Surg 1994;57:208 –10. 7. Lee FY, Wang YT, Poh SC. Congestive heart failure due to a pancreatic pseudocyst. Clev Clin J Med 1994;61:141–3. 8. Pavlovsky M, Perejaslov A, Chooklin S, Dovgan Y. Current management of pancreatic pseudocysts. Hep-Gastro 1998;45: 846 – 8.
Vol. 95, No. 12, 2000 ISSN 0002-9270/00/$20.00 PII S0002-9270(00)02180-8
Mediastinal Extension of a Pancreatic Pseudocyst Edward A. Rose, M.D., M.S.A., F.A.A.F.P., Munawar Haider, M.D., F.R.C.S., Sung K. Yang, M.D., and A. J. Telmos, M.D., F.A.C.S. Department of Family Medicine; Department of Internal Medicine, Division of Gastroenterology; Department of Surgery, Division of General Surgery, Wayne State University, Detroit, Michigan
INTRODUCTION Pancreatitis is a relatively common condition. Pseudocysts can complicate some cases. The diagnosis of pancreatic pseudocysts has been greatly aided by ultrasonography, computed tomography (CT), and magnetic resonance imaging (MRI). Most pseudocysts are intra-abdominal, with extra-abdominal extension being uncommon. We report a case involving pancreatic pseudocyst that was found in an unusual location.
CASE REPORT A 48-yr-old male with a history of recurrent pancreatitis, alcoholism, and type 2 diabetes mellitus presented to the emergency room with a 5-day history of abdominal pain. The pain started after a bout of heavy alcohol intake. He described the pain as sharp and continuous, located in the epigastrium, with radiation to the back in the interscapular region. Bending forward relieved the pain. Physical examination was noncontributory. Laboratory studies revealed a normal blood count. Plasma sodium was low at 129 mmol/L, with a normal potassium (4.4 mmol/L). Serum amylase and lipase were 37 U/L and 128 U/L, respectively. An ultrasound revealed increased echogenicity of the head of the pancreas with possible calcifications, as well as the presence of gallstones along with a small stone in the common bile duct. An endoscopic retrograde cholangiopancreatography (ERCP) procedure was planned, with the intent of sphincterotomy and removal of the common bile duct stone. At ERCP (Fig. 1) no stone was visualized after injection of the contrast agent. However, contrast did fill what appeared to be a pancreatic pseudocyst that extended into the mediastinum; this measured 3 ⫻ 10 cm in length. The endoscopist had the impression that the pseudocyst seemed to empty back into the fundus of the stomach. A CT scan performed immediately postprocedure (Fig. 2) confirmed the mediastinal extension of approximately 4 cm of the pancreatic pseudocyst but revealed no evidence of a fistula into the stomach. The patient was taken to the operating room the following day. At the time of surgery, the surgical team was unable to
identify the abdominal portion of the pseudocyst, confirming that the pseudocyst seen on ERCP was, in fact, the mediastinal pseudocyst seen on CT scan. The postoperative course was uneventful. One month postoperatively, the patient was asymptomatic. A follow-up CT scan was planned, but the patient has been lost to follow-up.
DISCUSSION Pancreatic pseudocysts are a recognized complication of both acute and chronic pancreatitis. Pseudocysts are said to occur in 16 –50% of cases of acute pancreatitis, and in 20 – 40% of cases of chronic pancreatitis (1). Seventy to eighty percent of pancreatic pseudocysts are said to be related to alcoholic pancreatitis, with the remainder being associated with gallstone pancreatitis, trauma, hyperlipidemia, or recent surgical operations or procedures (e.g., ERCP) (1).
Figure 1. ERCP showing pseudocyst opacified (C ⫽ pseudocyst, PD ⫽ pancreatic duct).
AJG – December, 2000
Mediastinal Extension of a Pancreatic Pseudocyst
3639
external drainage, and nonoperative radiographic and endoscopic drainage techniques have been described (1, 2). Because predominantly mediastinal pseudocysts are unsuitable for endoscopic decompression, and radiologic (percutaneous) access may be difficult or impossible, most symptomatic cases require surgical management. Because our patient was a candidate for cholecystectomy and had what appeared to be an extensive pancreatic pseudocyst, we opted for an open procedure that would allow not only the cholecystectomy, but also evaluation and possible surgical drainage of the pseudocyst. Postoperatively he did well, with resolution of all symptoms. Figure 2. CT scan showing section through lower chest (C ⫽ pseudocyst, ES ⫽ esophagus, DA ⫽ descending aorta, LA ⫽ left atrium).
A vast majority of pancreatic pseudocysts are located in the abdomen, retroperitoneally behind the pancreas. Less than 50 cases of mediastinal pancreatic pseudocysts have been reported in the English language literature (2–5). Such pseudocysts tend to be located in the posterior mediastinum, having extended through the aortic or esophageal hiatus (2, 5). The symptoms associated with mediastinal pancreatic pseudocysts tend to be nonspecific, as in the current case. Abdominal pain; nausea; vomiting; and chest, back, and shoulder pain have been reported (2). Dysphagia, pleural effusions (3), spontaneous esophageal fistulization (6), and even congestive heart failure (7) also have been reported. The management of mediastinal pancreatic pseudocysts is controversial and depends, in part, on their size. Small pseudocysts (⬍5 cm in diameter) (8) may resolve spontaneously over the course of several weeks and may be managed conservatively. Larger pseudocysts have a higher probability of complications, and are therefore more likely to require definitive therapy. Surgical resection, internal or
Reprint requests and correspondence: Edward A. Rose, M.D., Department of Family Medicine, 26454 Woodward Ave., Royal Oak, MI 48067-0919. Received June 17, 1998; accepted Mar. 25, 1999.
REFERENCES 1. Grace PA, Williamson RCN. Modern management of pancreatic pseudocysts. Br J Surg 1993;80:573– 81. 2. Gentry SE, Harris MA. Posterior mediastinal mass in a patient with chest pain. Chest 1995;107:1757–9. 3. Zeilender S, Turner MA, Gauser FL. Mediastinal pseudocyst associated with chronic pleural effusions. Chest 1990;97: 1014 – 6. 4. LeRoux BT, Kallichrum S, Shama DM. Mediastinal cysts and tumors. Curr Probl Surg 1984;21:1–76. 5. Casson AG, Inculet R. Pancreatic pseudocyst: An uncommon mediastinal mass. Chest 1990;98:717– 8. 6. Landrenau RJ, Johnson JA, Keenan RJ, et al. “Spontaneous” mediastinal pancreatic pseudocyst fistulization to the esophagus. Ann Thor Surg 1994;57:208 –10. 7. Lee FY, Wang YT, Poh SC. Congestive heart failure due to a pancreatic pseudocyst. Clev Clin J Med 1994;61:141–3. 8. Pavlovsky M, Perejaslov A, Chooklin S, Dovgan Y. Current management of pancreatic pseudocysts. Hep-Gastro 1998;45: 846 – 8.