A 42-year-old alcoholic man had recurrent upper abdominal pain accompanied by breathlessness
and right-side pleuritic chest pain for 5 months. Examination revealed right-sided
pleural effusion. He had normal hemogram, liver, and renal function tests, normal
serum amylase and a normal calcium profile. Thoracentesis from the right-sided pleural
effusion revealed no cells, a high protein content (4.3 g/dL), and elevated amylase
(2800 IU/L). Tube drainage of the right pleural effusion was done; it continued to
drain 200 – 400 mL/day of clear fluid with a high amylase content.
A contrast-enhanced computed tomography (CECT) scan of the chest and abdomen showed
a small abdominal pseudocyst (pancreatic pseudocyst), right-sided pleural effusion,
and a 5-cm pseudocyst in the posterior mediastinum compressing the lower end of the
esophagus with its proximal dilatation ([Fig. 1]). Endoscopic ultrasound (EUS) revealed features of chronic noncalcific pancreatitis
along with a mediastinal pseudocyst that was displacing the descending aorta posteriorly
([Fig. 2]). Endoscopic retrograde cholangiopancreatography (ERCP) was performed. Contrast-free
deep cannulation of the pancreatic duct was achieved ([Fig. 3]), and a 5-Fr pancreatic stent was placed.
Fig. 1 Contrast-enhanced computed tomography (CECT): mediastinal pseudocyst (white arrows)
compressing the esophagus with its proximal dilatation (arrow heads). Also note the
right-side pleural effusion (stars) with intercostal draining tube in situ.
Fig. 2 Endoscopic ultrasound (EUS): pseudocyst in the paraesophageal location anterior to
the descending aorta.
Fig. 3 Endoscopic retrograde pancreatography (ERP): guide wire taken into the area of pancreatic
duct disruption in the mediastinum.
The patient had marked improvement in his symptoms, with resolution of abdominal pain
and cessation of chest tube drainage within 2 weeks of stent insertion. The chest
tube was removed, and repeat CECT of the chest and abdomen at 4 weeks showed resolution
of all the pseudocysts and pleural effusion.
However, the patient started complaining of dysphagia to solids, which gradually worsened.
Endoscopy revealed a non-negotiable stricture at the lower end of the esophagus. EUS
with a radial echoendoscope from the mouth of the stricture revealed thickening of
the esophageal wall with loss of the layered pattern of the esophageal wall ([Fig. 4]). Endoscopic dilation was performed with bougie dilators, and the stricture was
gradually dilated up to 15 mm in diameter. With this, there was marked improvement
in the patient’s symptoms. After 3 months of follow-up, the patient remained asymptomatic.
Fig. 4 Endoscopic ultrasound (EUS): marked asymmetrical thickening of the esophageal wall
with loss of its layered pattern.
In spite of their location, mediastinal pseudocysts rarely cause dysphagia and are
usually associated with pleural effusion [1]
[2]
[3]. Conservative medical therapy with somatostatin or its analogues and endoscopic
(transpapillary or transmural drainage), surgical, or percutaneous drainage methods
have been successfully used for symptomatic mediastinal pancreatic pseudocysts [1]. Resolution is usually uneventful, but sometimes the healing process may cause intense
fibrotic reaction in the surrounding tissues, causing complications [4].
Endoscopy_UCTN_Code_CCL_1AB_2AC_3AD
