Acute Pancreatitis with Severe Mediastinal Fluid Accumulation via Retrocrural Space: An Indication for Single Dose Radiation Therapy?

Abstract

51 year old male malnourished alcoholic with 10 day history of worsening epigastric pain and melena. Had CT findings and lipase elevation consistent with acute pancreatitis, as well as anemia and elevated BUN concerning for upper gastrointestinal bleeding. His initial fluid resuscitation was limited by severe hyponatremia. Patient was high risk for osmotic demyelination with his poor nutritional status, so was given only modest volumes of normal saline over first 48 hours. EGD performed, revealed single nonbleeding esophageal ulcer, and single nonbleeding duodenal ulcer. Started on clear liquid diet after procedure, quickly advanced to full diet within 72 hours of admission. He continued to have persistent epigastric pain, unsure whether the etiology was from his ulcers or from the pancreatitis, as symptoms improved slightly with carafate. Repeat imaging one week after admission showed worsening of peripancreatic inflammation with new complex, partially loculated fluid in chest, abdomen, and mediastinum. Patient made NPO and started on total parenteral nutrition. Thoracic surgery consulted, and attempted ultrasound thoracentesis, but unable to remove therapeutic amount of fluid secondary to extensive adhesions. Pleural fluid amylase elevated at 380, cultures negative. Attempted MRCP, but patient unable to tolerate exam secondary to dyspnea. Single dose radiation therapy, as well as ERCP discussed at this time, but patient's respiratory status decompensated requiring intubation and pressor support. Images 1 and 2 were taken once in ICU intubated and sedated, showing extensive cystic fluid collections throughout his chest and abdomen, most impressively tracking up into the mediastinum and neck, likely via the retrocrural space, as illustrated in image 2. The fluid collections in his neck were so extensive they made tracheostomy impossible, patient made comfort care only, and died shortly after withdrawing pressors. This case stimulates discussion regarding the possible dangers of early refeeding while patients are still symptomatic, as well as when to perform high risk ERCP. This case should spark more discussion regarding single dose radiation therapy for control of fluid accumulation in the setting of complicated acute pancreatitis, especially when patient has mediastinal involvement resulting in respiratory compromise, and limited surgical options.1338_A.tif Figure 1: Coronal image of CT chest abdomen and pelvis with contrast, showing extensive cystic fluid collections in the neck, mediastinum, chest, abdomen, and psoas1338_B.tif Figure 2: Transverse image of CT chest abdomen and pelvis with contrast showing peripancreatic fluid tracking superiorly through the retrocrural space into mediastinum