JOP. J Pancreas (Online) 2005; 6(4):359-364.

JOP. Journal of the Pancreas – http://www.joplink.net – Vol. 6, No. 4 – July 2005. [ISSN 1590-8577] 359

CASE REPORT

Successful Resolution of a Mediastinal Pseudocyst and PancreaticPleural Effusion by Endoscopic Nasopancreatic Drainage

Deepak Kumar Bhasin, Surinder Singh Rana, Vijant Singh Chandail, Mohit Nanda,Saroj Kant Sinha, Birinder Nagi

Department of Gastroenterology,Post Graduate Institute of Medical Education and Research (PGIMER). Chandigarh, India

ABSTRACT

Context A mediastinal pseudocyst is anunusual complication of acute and chronicpancreatitis. The ideal form of management iscontroversial, and various successfultherapeutic interventions including surgicalresection, internal or external drainage, andnon-operative radiological drainagetechniques have been described. Successfulresolution of a mediastinal pseudocyst withendoscopic transpapillary stent placement hasbeen described in fewer than five cases.

Case report We report a case of chronicpancreatitis with complete pancreas divisumtogether with a mediastinal pseudocyst andpancreatic pleural effusion in which magneticresonance imaging and endoscopic retrogradepancreatography demonstrated communicat-ion of the abdominal pseudocyst with theposterior mediastinum through thediaphragmatic hiatus. This case was succes-sfully treated with endoscopic transpapillarynasopancreatic drain placement alone.

Conclusion A communicating mediastinalpseudocyst can be successfully treated byendoscopic transpapillary nasopancreaticdrainage alone.

INTRODUCTION

Extra abdominal localization of pancreaticpseudocysts is infrequent and themediastinum is a rare site for pancreaticpseudocysts [1, 2, 3, 4, 5, 6, 7, 8].Approximately 50 cases have been reported inthe literature with the majority occurring as acomplication of alcoholic pancreatitis [1, 2, 3,4, 5, 6, 7, 8]. The successful resolution of amediastinal pseudocyst with endoscopictranspapillary stent placement alone or inconjunction with somatostatin orpercutaneous drainage has been reported infewer than five patients [7, 8].We report a case of chronic pancreatitis withcomplete pancreas divisum in a non-alcoholicmale which was complicated by abdominaland mediastinal pseudocysts and pancreaticpleural effusion. Magnetic resonance imaging(MRI) of the abdomen demonstratedcommunication of the abdominal pseudocystwith the posterior mediastinum through thediaphragmatic hiatus. The patient wassuccessfully treated with transpapillarynasopancreatic drain placement alone.

CASE REPORT

A 28-year-old male had had pancreatic painfor 2 years and breathlessness for 15 days.

JOP. J Pancreas (Online) 2005; 6(4):359-364.

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There was no history of alcohol ingestion.Hemoglobin, total and differential leukocytecount, liver function tests, renal function tests,serum electrolytes and amylase level werenormal. A chest radiograph revealed left sidedpleural effusion. Contrast enhancedcomputerized tomography (CECT) of thechest and abdomen demonstrated abdominaland mediastinal pseudocysts and bilateralpleural effusion (Figures 1 and 2). Diagnosticthoracentesis revealed an exudative pleuralfluid with an amylase level of 8,624 IU/L(reference range: 0-160 IU/L). A MRI of theabdomen demonstrated communication of theabdominal pseudocyst with the posteriormediastinum through the diaphragmatichiatus (Figure 3).

Informed consent was obtained andendoscopic retrograde pancreatography wasperformed which revealed evidence ofcomplete pancreas divisum. A guide-wireassisted minor papilla cannulation wasperformed using a 0.035-inch Jag guide wire(Boston Scientific Corporation, Watertown,MA). The dorsal duct was dilated and therewas rupture of the pancreatic duct at the mid-body with the contrast tracking into themediastinum (Figure 4). A 5-Frnasopancreatic drain (NPD) was placed acrossthe rupture.Following this, the patient’s symptomsgradually resolved. Repeat chest andabdomen CECT performed after 4 weeksrevealed the complete resolution of bothabdominal and mediastinal pseudocysts andof the bilateral pleural effusion (Figures 5 and6). The pancreatogram obtained through theNPD after 4 weeks demonstrated healing ofductal rupture and the NPD was removed.After 1 year of follow-up, the patient issymptom free.

Figure 1. Contrast enhanced computerized tomographyof the abdomen reveals abdominal pseudocyst.

Figure 2. Contrast enhanced computerized tomographyof the chest reveals a mediastinal pseudocyst withbilateral pleural effusion (L>R).

Figure 3. Magnetic resonance imaging of the abdomenshows a track through which the abdominal pseudocystcommunicates with the posterior mediastinum throughthe diaphragmatic hiatus. Left sided pleural effusion isalso seen.

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DISCUSSION

Mediastinal pseudocysts, a rare complicationof pancreatitis, have been reported in patientsranging from 7 months to 73 years of age [1].Alcohol-induced pancreatitis is responsiblefor the majority of cases of pseudocysts inadults and trauma is the cause in children [1].Underlying chronic pancreatitis withcomplete pancreas divisum, as noted in the

present case, has rarely been described inpatients with mediastinal pseudocysts [7].A mediastinal pseudocyst is caused by therupture of the pancreatic duct posteriorly intothe retroperitoneal space. In the majority ofpatients, the pancreatic fluid enters themediastinum through the esophageal or aortichiatus [1]. Thus, mediastinal pseudocysts arecommonly located in the posteriormediastinum. Other less frequent sites ofentry into the mediastinum are the foramen ofMorgagni, the inferior vena cava hiatus anddirect penetration of the diaphragm [1, 7].Mediastinal pseudocysts may rupture into thepleural space producing pleural effusion ormay extend further into the neck [1, 3, 9]. Upto 54% of cases of mediastinal pseudocystshave associated pleural effusion as waspresent in our case [1]. In spite of mediastinalinvolvement by the pseudocyst, dysphagia is arare symptom [10].Although ultrasound is a quick, inexpensiveradiological investigation for diagnosingintraabdominal pseudocysts, it cannotdetermine the presence of mediastinalextension. Imaging modalities, such ascomputerized tomography (CT) or MRI, areindispensable diagnostic modalities indefining the location and extent of

Figure 6. Contrast enhanced computerized tomographyof the chest, performed 4 weeks post endoscopicretrograde pancreatography, shows the completeresolution of mediastinal pseudocyst and pleuraleffusion.

Figure 4. An endoscopic retrograde pancreatogramshows ductal rupture at the body level with the contrasttracking towards the mediastinum. A guide wire hasbeen negotiated across the rupture.

Figure 5. Contrast enhanced computerized tomographyof the abdomen, performed 4 weeks post endoscopicretrograde pancreatography, shows the completeresolution of the abdominal pseudocyst.

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mediastinal pseudocysts [1]. MRI can alsohelp in delineating the communication ofmediastinal pseudocysts with an abdominalpseudocyst as was noted in the current case[1, 11, 12]. Newer techniques, such asendoscopic ultrasound (EUS) and EUS guidedfine needle aspiration, have been reported tobe extremely useful in diagnosing mediastinalmasses [13]. EUS-guided aspiration of fluidfrom a mediastinal cyst with an elevatedamylase level can confirm the diagnosis of amediastinal pseudocyst [14].The ideal management of mediastinalpseudocysts is controversial and depends onthe underlying etiology, ductal anatomy, sizeof the pseudocyst and expertise available.Small pseudocysts may resolve spontaneouslybut this is a rare event and requires prolongedconservative management [2, 4]. Somatostatinor its analogues can also be used but thisusually requires prolonged therapy [5, 7].Successful resolution of mediastinalpseudocysts with 5-months of therapy withthe mucolytic agent bromhexinehydrochloride has also been reported [15].Radiologically guided percutaneous drainageis a less invasive therapeutic option with alower mortality rate as compared to thesurgical treatment; however, the risk ofinfection, blockade of catheters, fistulaformation and recurrence are the majorlimitations of radiological drainage [6, 7].Surgical treatment has been the mostcommonly used therapeutic modality forpatients with mediastinal pseudocyst [1]. Thesurgical procedures described are varied andinclude pancreatic resection or external orinternal drainage [1, 2, 16, 17]. Successfulresolution of mediastinal pseudocysts withless invasive procedures, such as combinedlaparoendoscopic or thoracoscopicapproaches has also been reported [17, 18].While endoscopic therapeutic options,including transmural drainage ortranspapillary stent placement, have beensuccessfully used in patients with abdominalpseudocysts [19, 20, 21, 22, 23, 24, 25], thereare few reports describing the successfulresolution of mediastinal pseudocysts withendoscopic intervention [7, 8, 14]. A case of

successful resolution of a mediastinalpseudocyst by endoscopic transhiatal drainageafter performing transgastric transhiatalpuncture of the cyst under EUS guidance hasbeen reported [14]. EUS-guidedtransesophageal pseudocyst drainage has alsobeen described and it can also be considered aviable option for the treatment of mediastinalpseudocysts [26]. Successful resolution ofmediastinal pseudocysts with endoscopictranspapillary stent placement alone has rarelybeen described [7, 8].We successfully treated our patient withendoscopic transpapillary nasopancreaticdrainage through the minor papilla withoutthe concurrent administration of somatostatinor percutaneous drainage. Like a stent, theplacement of a transpapillary nasopancreaticdrain could facilitate the healing of ductalruptures by partially occluding the leakingduct or by traversing the pancreatic sphincterconverting the high-pressure pancreatic ductsystem to a low-pressure system withpreferential flow through the NPD [27].Moreover, the NPD helped us in documentingthe healing of pancreatic duct rupture byperforming a nasopancreatogram through theNPD following which the NPD could beremoved without the need of additionalendoscopy.To conclude, a mediastinal pseudocyst is arare complication of chronic pancreatitiswhich can be treated by endoscopictranspapillary nasopancreatic drainage.

Received April 26th, 2005 - Accepted May20th, 2005

Keywords Cholangiopancreatography,Endoscopic Retrograde; PancreaticPseudocyst; Pancreatitis

Abbreviations CECT: contrast enhancedcomputerized tomography; NPD:nasopancreatic drain

CorrespondenceDeepak Kumar Bhasin1041, Sector 24-B

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Chandigarh - 160 023IndiaPhone: +91-172.271.5056/5870Fax: +91-172.274.4401E-mail:dkbhasin@sancharnet.in;

dkbhasind@hotmail.com

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