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Weekly Chest CasesArchive of Old Cases

Case No : 1107 Date 2019-01-14

  • Courtesy of Mi Jung Park, Kyung Nyeo Jeon / Gyeongsang National University
  • Age/Sex 46 / F
  • Chief ComplaintEpigastric pain for 2 days
  • Figure 1
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Diagnosis With Brief Discussion

Diagnosis
Ruptured pancreatic pseudocyst in the mediastinum
Radiologic Findings
Chest PA view shows obliteration of azygo-esophageal recess and bilateral pleural effusion.
On CT image, multiloculated fluid collection is noted in the posterior mediastinum. Thin walled, hypodense cystic mass is seen to the distal esophagus. The lesion extends inferiorly into stomach and peripancreatic region through the esophageal hiatus. Small bilateral pleural effusion also seen.

The amylase and lipase was elevated in the aspirated fluid (1283/700).
Brief Review
Pancreatic pseudocysts are a common complication of both acute and chronic pancreatitis. They are usually located in peripancreatic area and very rarely may reach the mediastinum.
Patho-physiologically, mediastinal pseudocyst can develop after rupture of the pancreatic duct into the retroperitoneal space. The pancreatic fluid then tracks through the diaphragmatic openings such as esophageal and aortic hiatus into the mediastinum.
Symptoms are primarily the results of compression or invasion of the mediastinal structures and may include dysphagia, odynophagia, weight loss, abdominal, chest and/or back pain, dyspnea, and cough.
A chest radiograph may be of low diagnostic yield, but may show retrocardiac opacity, pleural effusion, and atelectasis of basal lungs. Contrast-enhanced CT scan can show a thin-walled low-attenuating cystic mass extended from the pancreas into the mediastinum. Magnetic resonance cholangiopancreatography can help identify the connection between the mediastinal and abdominal pseudocyst in cases where it not so evident on CT scan. Endoscopic ultrasound is increasingly used in evaluating pancreatic cysts due to its advantages in delineating contents and wall of the cysts.
An elevated amylase or lipase level in the aspirated fluid from the mediastinal pseudocyst can confirm the diagnosis.
Spontaneous regression of mediastinal pseudocysts is rare and therapeutic intervention is frequently required. It includes surgical drainage such as open laparotomy and percutaneous approach, and endoscopic drainage methods.
Pseudocysts should be considered in the differential diagnosis of mediastinal masses in patents with a history of pancreatitis.
References
1. Drescher R, Koster O, Lukas C. Mediastinal pancreatic pseudocyst with isolated thoracic symptoms: a case report. Journal of Medical Case Reports 2008, 2:180.
2. Gupta R, Munoz JC, Garg P, et al. Mediastinal Pancreatic Pseudocyst-A Case Report and Review of the Literature. Medscape General Medicine. 2007; 9(2): 8.
3. Kirchner SG, Heller RM, Smith CW. Pancreatic pseudocyst of the Mediastinum. Radiology 1997, 123:32-42.
Please refer to
Case 866 Case 1047
Keywords
Mediastinum, pleura, pancreas,

No. of Applicants : 72

▶ Correct Answer : 24/72,  33.3%
  • - The University of Kyoto Hospital , Japan TOMOAKI OTANI
  • - Showa University Fujigaoka Hospital , Japan KYOKO NAGAI
  • - Niigata University , Japan ATSUSHI UEHARA
  • - Higashi-Ohmi General Medical Center , Japan AKITOSHI INOUE
  • - Ajou University School of Medicine , Korea (South) JUNG YONG JUN
  • - Vita Hospital , Brazil DIOGO LAGO PINHEIRO
  • - Other , Korea (South) SEONGSU KANG
  • - The Jikei university , Japan TAKU GOMI
  • - The University of Tokyo Hospital , Japan TOSHIHIRO FURUTA
  • - Wuhan Union Hospital , China NANCHUAN JIANG
  • - Gifu University Hospital , Japan Yo Kaneko
  • - Chonbuk National University Hospital , Korea (South) YOUNGKWANG LEE
  • - , United States MAANSI P
  • - Diskapi Yildirim Beyazit Hospital, Ankara , Turkey MERIC TUZUN
  • - Ajou University Hospital , Korea (South) HYERIN KIM
  • - Azienda Ospedaliera di Cremona , Italy Pietro Sergio
  • - Korea University Guro Hospital , Korea (South) KYU-CHONG LEE
  • - Teikyo University Hospital , Japan KAORU SUMIDA
  • - Ichinomiya Nishi Hospital , Japan Takao Kiguchi
  • - , Korea (South) JONGSUN LEE
  • - Hamamatsu University Hospital , Japan YUKI HAYASHI
  • - Japanese Red Cross Wakayama Medical Center , Japan AKIHIKO SAKATA
  • - Ajou University Hospital , Korea (South) YONG HO JANG
  • - Jiangsu province hospital , China WANGJIAN ZHA
▶ Correct Answer as Differential Diagnosis : 5/72,  6.9%
  • - Saitama-Sekishinkai Hosptal , Japan MIHOKO YAMAZAKI
  • - McGill University Health Center , Canada Alexandre Semionov
  • - , Korea (South) JANG SEONG WON
  • - Pavilh李 , Brazil THIAGO KRIEGER BENTO DA SILVA
  • - , Japan YUMI MAEHARA
▶ Semi-Correct Answer : 7/72,  9.7%
  • - Showa university Northern Yokohama Hospital , Japan KOTA WATANABE
  • - MD , India DEEPANDER SINGH RATHORE
  • - Oita University, Faculty of Medicine , Japan Fumito Okada
  • - CLINIQUE STE CLOTILDE , Reunion PATRICK MASCAREL
  • - , Korea (South) SEUNGYOON CHAE
  • - Fortis hospital , Mohali , India SHALEEN RANA
  • - Kizawa Memorial Hospital , Japan Shoji Okuda
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