Mediastinal Extension of a Pancreatic Pseudocyst: A Rare Cause of Dysphagia in the Setting of Pancreatitis

Abstract

Introduction: Pseudocysts are a common complication of acute or chronic pancreatitis and are also seen following pancreatic trauma. However, mediastinal extension of a pancreatic pseudocyst is rare. Case: A 40-year-old man was admitted to our hospital with progressive dysphagia and vomiting after meals for 4 days. He had a previous admission for acute alcoholic pancreatitis with pancreatic pleural effusion a year before. After the previous discharge, he was not able to quit alcohol consumption completely after his temporary abstinence. His medications included camostat mesilate and rabeprazole sodium. However, he stopped taking his medications and consumed alcohol frequently over the past 4 months. Chest roentgenogram revealed a distinctly defined retrocardiac mass in the posteroinferior mediastinum. Upper gastrointestinal endoscopy revealed stasis at the lower end of the esophagus, which was compressed extrinsically. Computed tomography scan demonstrated a pancreatic pseudocyst arising from the tail of the pancreas and extending through the diaphragmatic hiatus into the posteroinferior mediastinum. The esophagus was compressed extrinsically by the pseudocyst, which resulted in dysphagia. Treatment consisted of abstinence, fasting, and fluid replacement. His condition improved rapidly and dysphagia also resolved. He left the hospital 10 days after admission and was asymptomatic. Discussion: The mediastinum is a rare site for pancreatic pseudocysts. A mass in this site can cause anterior and lateral displacement of the esophagus and the stomach, which may result in dysphagia. The ideal management for mediastinal pseudocyst is controversial and depends on the underlying etiology, severity of symptoms, ductal anatomy, size of the pseudocyst and expertise available. Successful medical treatments such as somatostatin analogues, total parenteral nutrition, and watchful waiting for spontaneous regression have been previously reported. Pseudocyst internal or external drainage techniques have also been described as being effective, and can involve percutaneous external drainage, surgery such as cystogastrostomy, and endoscopic internal drainage such as transpapillary and transgastric techniques. Our patient was treated with conservative medical management based on his mild symptoms and a spontaneous resolution of the pseudocyst was obtained. Conclusion: Mediastinal pancreatic pseudocyst as a cause of dysphagia is very rare. As the condition can be life threatening, gastroenterologists should be aware of this atypical complication of pancreatitis, although it is rare.