A Rare Cause of Dysphagia: Mediastinal Pancreatic Pseudocyst

Abstract

Mediastinal pancreatic pseudocysts are a rare complication of acute and chronic pancreatitis. They occur as a result of posterior rupture of the pancreatic duct into the retroperitoneal space and subsequent drainage of pancreatic fluids though the diaphragmatic orifices into the mediastinum. No uniform diagnostic or treatment standards exist in the management of these cysts. Here we report the case of a 50-year-old male with history of alcohol abuse and recurrent pancreatitis, last episode ten months prior, who presented with rapidly progressive dysphagia and odynophagia. He was previously evaluated at another institution where a cardiac workup was noted to be negative and he was discharged home with a diagnosis of esophageal spasm. On presentation to our facility, patient was afebrile, hemodynamically stable, with a normal physical exam and normal labs. Chest radiography on admission showed small pleural effusions bilaterally and bibasilar opacities attributed to atelectasis or pneumonia. CT chest was notable for multiple cystic lesions in the gastroesophageal (GE) junction and gastrosplenic regions with associated stenosis of the esophagus at GE junction (Figures 1 and 2). A subsequent CT abdomen and pelvis with contrast revealed a large 5 x 4 cm pseudocyst anterior to the distal GE junction with mass effect and compression. Endoscopic ultrasound (EUS) was performed revealing a heterogenous periesophageal cyst, measuring 4 cm x 6.7 cm with mixed liquid and solid components (Figure 3). The cyst fluid was successfully aspirated with a transesophageal FNA. The remaining cyst with solid debris measured 2.5 x 5 cm after drainage. Analysis of the aspirate was notable for an amylase level of 4136 (U/L) and CEA of 4.8 (mg/dL) thus confirming diagnosis of pseudocyst. The patient was subsequently discharged and has been symptom free since. There are fewer than 100 reported cases of mediastinal pancreatic cyst expansion. This case highlights a rare presentation of a common complication of recurrent pancreatitis and illustrates the importance of considering pancreatic pseudocyst expansion into the mediastinum as a cause of dysphagia and odynophagia in these patients.Figure: CT Chest demonstrating cyst compressing esophagus at GE junction in sagittal view.Figure: CT Chest demonstrating cyst compressing esophagus at GE junction in coronal view.Figure: EUS image of FNA needle in mediastinal pancreatic pseudocyst.