SUCCESSFUL ENDOSCOPIC TREATMENT OF SYMPTOMATIC MEDIASTINAL PSEUDOCYSTS

Abstract

Mediastinal pseudocysts are rare but can pose a diagnostic and therapeutic challenge. Recognizing their presence and instituting appropriate therapy can reduce morbidity and mortality. This report describes a 69-year-old patient with a history of alcohol abuse and pancreatitis who presented with progressive dyspnea, bilateral pleuritic chest pain, and cough. Significant findings on examination were diminished breath sounds and dullness to percussion bilaterally involving the lower one-third of the posterior lung bases. A chest x-ray showed bilateral pleural effusions, computerized tomography (CT) of the chest and abdomen revealed a fluid collection in the paraesophageal area measuring 4.2 × 1.7 cm, a calcification in the pancreatic duct with duct dilatation, a 3.7 × 2.4 cm fluid collection anterior to the pancreas, which had a severely atrophic body and tail. Thoracentesis revealed an elevated amylase and lipase in the pleural fluid and endoscopic retrograde cholangiopancreatography (ERCP) confirmed the stone in the main pancreatic duct, revealed a leak in the tail of the duct and a stent was placed. An enteral jejunal tube was placed for feeding after oral intake was stopped, and octreotide was started. A CT scan of the abdomen and pelvis performed 41 days after the first ERCP showed resolution of the mediastinal pseudocysts, pleural effusions, and dilatation of the pancreatic duct. A small 1.0 cm residual pseudocyst was identified in the pancreatic tail. The pancreatic stent was subsequently removed and the patient made a complete recovery, which persisted at 6-month follow-up. This case illustrates the fact that endoscopic treatment of mediastinal pseudocysts can be successful averting the need for surgery and its associated morbidity and mortality. A discussion of the current approaches to mediastinal pseudocyst management are presented.