A rare cause of mediastinal expansion with a massive pleural effusion

Abstract

The authors present a case of a 53 year old woman, who was admitted to hospital because of an unusual cause of massive pleural effusion. During diagnostic examination the mediastinal propagation of the pancreatic pseudocyst was discovered as a complication of the chronic calcifying pancreatitis. The patient was operated on and the pseudocyst was resolved by Roux-en-Y cystjejunostomy. The diagnostics and treatment of this unusual pancreatic pseudocyst spreading is discussed. P ancreatic pseudocysts are localised collections of the pancreatic juice surrounded by granulation tissue. They arise within the pancreas or in the peripancreatic space after an inflammatory process attributable to an acute and chronic pancreatitis or trauma. Pseudocysts develop in 5%-10% of patients with and acute episode of pancreatitis and in 20%-40% patients with chronic pancreatitis.1 Sometimes they can have a very uncommon localisation. CASE REPORTA 53 year old woman presented with a four week history of dyspnea, cough, and chest pain located behind the sternum and radiating to the left clavicle and back. The patient also complained of mild epigastric discomfort after oral intake and of nine kilograms weight loss within the past month. Eleven years before the admission the patient had been treated for three episodes of severe acute pancreatitis of biliary aetiology. There was also heart ischaemic disease with myocardial infarction 11 years previously and arterial hypertension in the patient's history.Examination showed dull percussion and weakened breath sounds on the chest right side. There was only mild increase of serum and urine amylase values in the laboratory findings (4.08 mkat/l, 8.25 mkat/l respectively; normal serum value in our laboratory: 0.47-1.67 mkat/l, urine concentration: 0-7.67 mkat/l), other laboratory tests were normal. ECG confirmed the history of the myocardial infarction but did not show any acute pathology.Chest radiography showed a massive right sided pleural effusion. Repeated thoracocenteses yielded amount of 3900 ml of sanguineous fluid with a high amylase activity, 93.3 mkat/l. Consecutive chest sonography confirmed residual pleural effusion and showed cystic expansion measuring 65-70 mm in diameter in the posterior mediastinum behind the left cardiac atrium. Bronchoscopy did not show any abnormality and TB was excluded.Computed tomography of the chest and abdomen was performed and helped establishing the final diagnosis. CT scan showed the right sided pleural effusion but not pulmonary parenchyma infiltration or mediastinal lymphadenopathy. Cystic expansion 906706140 mm in the lower part of the posterior mediastinum between aorta and cardiac atrium communicating with pancreas was also found. Pancreatic changes were consistent with chronic calcifying pancreatitis without dilatation of the main pancreatic duct (figs 1, 2). The definitive diagnosis was mediastinal extension of a pancreatic pseudocyst. An endoscopic retrograde cholangiopancreatography (ERCP) was not performed because the computed tomogram show...

Pancreaticopleural fistula: an overlooked entity

“…5 Some cases of mediastinal pancreatic pseudocyst have been reported wrongfully as a mediastinal mass on chest radiography. 2 There are no clear guidelines for PPF management because it is a rare entity. It has been reported that 50% of PPF will close with conservative measures, with subsequent resolution of effusion.…”

“…Pleural effusion is seen in 3%–17% of cases, and it indicates a worse prognosis. 2 In the setting of chronic pancreatitis where history of alcoholism can be elicited, 20%–40% of patients develop pseudocysts. 3 PPF is seen in less than 1% of acute pancreatitis cases but in 0.4%–4.5% of chronic pancreatitis cases.…”

“…5 Some cases of mediastinal pancreatic pseudocyst have been reported wrongfully as a mediastinal mass on chest radiography. 2…”

“…Such stenting reduces the intraductal pressure and seals the leak. 2,5,6 Endoscopic intervention in conjunction with total parenteral nutrition, octreotide, and chest drainage constitute the medical management. It has been reported that such an approach closes the fistula in 2–3 weeks in 48% of cases, with concurrent management of the underlying cause.…”

Pancreaticopleural and pancreaticomediastinal fistula extending to the cervical region, with dysphagia as initial symptom

“…[1] Many cases of pancreaticopleural fistulas and a few pancreatic pseudocysts penetrating to the mediastinum were described with complications such as mediastinitis, pneumonia, hemothorax, and heart tamponade. [3–5] The main symptoms are dyspnea, dysphagia, and chest pain. [6] Dysphagia rarely occurs as the presenting symptom and is more common in mediastinal fistulas.…”