An Unusual Case of Ascending Pancreatitis with Mediastinal Involvement: A Case Report with CT and MRI Findings

Abstract

Fluid collections are common findings of pancreatitis and spread, more often, along preferential drainage pathways in the abdomen. In some rare cases, fluid collections may spread towards extra-abdominal sites like the mediastinum leading to the formation of mediastinal collections. We present the case of a 52-years-old man with pain in the right upper quadrant of the abdomen and mid-epigastrium lasting for some hours. Laboratory tests suggested a diagnosis of pancreatitis. CT and subsequent MRI revealed changes consistent with acute exacerbation on chronic pancreatitis spreading to the mediastinum and to the greater omentum. The patient received medical treatment and reported gradual improvement in his laboratory results and CT findings.

Thoracic complications of pancreatitis

“…Less frequently, the collection can track and ascend anteriorly into the mediastinum through the foramen of Morgagni, the inferior vena cava hiatus, or into the retrocrural space by penetrating the left diaphragm . Anterior mediastinal pseudocysts can occur from an extension through the foramen of Morgagni, while middle mediastinal pseudocysts can occur through the diaphragmatic erosion or an inferior vena cava hiatus . Usually, the pancreatic secretions will spread preferentially into the posterior pararenal space and pelvic extraperitoneal space in acute pancreatitis.…”

“…CT is very sensitive and is the modality of choice in demonstrating pancreatic abnormalities and fluid collections (Fig. a, b) . It should be the first imaging study in cases suspected to have mediastinal pseudocysts.…”

“…MRI with MRCP can demonstrate fistulous communications with the pancreatic duct or the peripancreatic collections. In addition, ductal morphology, such as disruption, communication with pseudocyst, stricture, and dilatation, are best defined by MRCP . Endoscopic ultrasound (EUS) is an important diagnostic modality for the evaluation of mediastinal pseudocysts (Fig.…”

“…66 Anterior mediastinal pseudocysts can occur from an extension through the foramen of Morgagni, while middle mediastinal pseudocysts can occur through the diaphragmatic erosion or an inferior vena cava hiatus. 67,68 Usually, the pancreatic secretions will spread preferentially into the posterior pararenal space and pelvic extraperitoneal space in acute pancreatitis. Unusual drainage pathways can extend into the mediastinum.…”

“…3a, b). 67,68 It should be the first imaging study in cases suspected to have mediastinal pseudocysts. In these patients, the chest CT can be combined with the abdominal evaluation.…”