Endosonographic visualization of a mediastinal pancreatic pseudocyst

A 55-year-old woman with a history of chronic pancreatitis secondary to alcohol use presented initially with abdominal pain, unintentional weight loss, and progressive fatigue. A computed tomography (CT) scan revealed pancreatic inflammation and a 3-cm pancreatic pseudocyst, which was confirmed on endoscopic ultrasound (EUS), centered near the body of the pancreas.

Two months later, the patient’s symptoms returned despite symptom resolution during the initial hospitalization. In addition to her abdominal pain, the patient presented with hemoptysis and dysphagia. She was readmitted and chest CT identified a well-defined, rapidly expanding fluid collection that extended from the head of the pancreas to the mediastinum ([Fig. 1]). Therapeutic EUS-guided transmural drainage was planned; however, EUS examination revealed arterial flow in the mediastinal segment of the pseudocyst as well as a valve-like structure ([Fig. 2]) connecting the mediastinal and abdominal components of the pseudocyst ([Video 1]). Due to concern that transmural drainage would result in bleeding from vessels within the mediastinal component of the collection, drainage was not performed. Conservative management was pursued and follow-up EUS imaging 6 weeks later revealed diminished size of the pseudocyst.

Fig. 1 Chest computed tomography (coronal view). The hyperdense anomaly (arrow) represents a well-defined pseudocyst expanding into the mediastinum.

Fig. 2 Endoscopic ultrasound view of the mediastinal and abdominal components of the pseudocyst. The valve-like structure between the two components allowed communication between the mediastinal and abdominal segments.

Video 1 Endoscopic ultrasound visualization of a large pseudocyst extending from the head of the pancreas to the mediastinum with identification of a valve-like structure between the abdominal and mediastinal components.

Mediastinal pancreatic pseudocysts are a rare complication of acute or chronic pancreatitis that have been sporadically reported in case reports [1] [2]. EUS-guided drainage offers a potential treatment option with rapid symptom resolution [3]. Symptom recurrence after endoscopic drainage, however, may prompt surgical intervention. This case highlights a situation in which conservative management may be beneficial, demonstrating the value of EUS and Doppler imaging to determine the safety of endoscopic pseudocyst drainage.

Endoscopy_UCTN_Code_CCL_1AF_2AZ

Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Bhasin DK, Rana SS, Rao C. et al. Clinical presentation, radiological features, and endoscopic management of mediastinal pseudocysts: experience of a decade. Gastrointest Endosc 2012; 76: 1056-1060
• 2 Mallavarapu R, Habib TH, Elton E. et al. Resolution of mediastinal pancreatic pseudocysts with transpapillary stent placement. Gastrointest Endosc 2001; 53: 367-370
• 3 Gornals JB, Loras C, Mast R. et al. Endoscopic ultrasound-guided transesophageal drainage of a mediastinal pancreatic pseudocyst using a novel lumen-apposing metal stent. Endoscopy 2012; 44 (Suppl. 02) E211-212

Publication History

Article published online:
18 November 2022