Mediastinal pseudocyst.

Abstract

The incidence of pancreatic pseudocyst increases considerably in institutions in which there is a high incidence of chronic alcoholism. It is not unusual to see 25 to 30 cases in a year at the Cook County Hospital. Even with this volume of a relatively uncommon disease we have not encountered mediastinal extension of a pseudocyst prior to this case presentation. Up to the present 6 such cases have been reported (2, 3, 6, 8–10). A 33-year-old Negro male entered Cook County Hospital with a chief complaint of persistent abdominal pain of several days duration. Two years earlier he had undergone ligation of inferior vena cava because of repeated episodes of pulmonary emboli which were not controlled by adequate anticoagulation therapy. He improved after his surgery. However, sputum cultures obtained during this admission were reported positive for tuberculosis, and he was placed on isoniazid and followed as an out-patient at the Municipal Tuberculosis Clinics. At no time was a posterior mediastinal mass noted on radiographs taken up to six months before his present admission. The patient was a chronic alcoholic who admitted he drank about a fifth of bourbon daily. Upon admission, the physical examination revealed a vague fullness and slight tenderness in the epigastrum and slight edema in both lower extremities. Chest radiographs demonstrated a posterior mediastinal mass. An upper gastrointestinal series showed a definite rounded mass which compressed and displaced the fundus, body of stomach, and distal esophagus anteriorly. A definite soft-tissue indentation was seen on the medial aspect of the fundus (Fig. 1). To further evaluate this mass abdominal aortography was performed, revealing a normal-size aorta. The patient refused inferior vena cavography, and surgery was carried out. Abdominal exploration disclosed a huge mass adherent to the posterior wall of the stomach, which extended through the esophageal hiatus and displaced the esophagus anteriorly. The mass arose from the body of the pancreas and, when probed, yielded 500 cc of fluid with a serum amylase of 2048 units. A cystogastrostomy was performed. On the patient's return one year later, the pancreatic pseudocyst was recurrent, without the mediastinal extension. Discussion Since 1951, 6 cases of pancreatic pseudocyst with extension into the posterior mediastinum have been reported in American literature (2, 3, 6, 8–10). Five of these cases occurred in adults (2, 3, 8–10) and 1 in a child (6). In 2 of these (as in ours) the extension into the chest took place through the esophageal hiatus (3, 6), while extension through the aortic hiatus accounted for 2 others (2, 9). In 1 of the remaining 2 cases no data were available concerning this point, and in the other (10) herniation occurred through both hiatuses. Calcification was noted in 2 instances. In 2 of the 6 cases there was displacement of the barium-filled esophagus, unaccompanied by displacement of the stomach.