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A patient with new onset of thoracic pain, dyspnoea and weight loss
  1. G Lohr1,
  2. C Luft2,
  3. K Lenz1
  1. 1
    Department of Internal Medicine, Konventhospital Barmherzige Brueder, Linz, Austria
  2. 2
    Department of Radiology, Konventhospital Barmherzige Brueder Linz, Austria
  1. Correspondence to Dr G Lohr, Konventhospital Barmherzige Brueder, Seilerstaette 2, A-4020 Linz, Austria; gerald.lohr{at}bblinz.at

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Clinical presentation

A 55-year-old man with a long history of recurrent alcohol-induced chronic pancreatitis was admitted to our hospital with new onset dyspnoea, epigastric and thoracic pain, and nausea. Clinical examination was in addition to pressure pain and resistance in the epigastrium normal. Laboratory results showed an elevation of inflammation markers (C-reactive protein, 9 mg/dl) and elevated liver (γ-glutamyl transferase, 324 U/l; alkaline phosphatase, 308 U/l) and pancreatic enzymes (amylase, 181 U/l; lipase, 93 U/l).

A computed tomography scan of the abdomen and thorax was performed (figs 1–3).

Figure 1

Sagittal reconstruction of the abdominal and thoracic computed tomography scan.

Figure 2

Axial reconstruction of the abdominal and thoracic computed tomography scan.

Figure 3

Coronal reconstruction of the abdominal and thoracic computed tomography scan.

Question

What does the computed tomography scan show and what is the diagnosis?

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Answer

The computed tomography (CT) scan shows a large (10×12 cm) cystic lesion penetrating through oesophageal hiatus into the mediastinum and reaching the left atrium of the heart. It communicates with multiple confluent pancreatic pseudocysts, which were found in the entire upper abdomen, and which were diagnosed by a CT scan 1 year earlier. A large pleural effusion on the right side was also seen on the CT scan. With the help of endoscopic ultrasound (EUS)-guided fine-needle aspiration fluid samples could be taken and showed high levels of amylase, so the diagnosis of a large mediastinal pancreatic pseudocyst could be obtained. The pseudocyst nearly resolved after 45 days of conservative treatment and one-time thoracocentesis, in which 1000 ml of the fluid was removed, without the need of a surgical or endoscopic intervention. Because of another acute exacerbation of the chronic pancreatitis a few weeks after this episode and the development of a post-pancreatitic mild diabetes mellitus the patient finally decided to quit alcohol abuse and to follow the recommended diet. Since then the patient has remained free of pain, he has had no hospital admissions for more than a year, and the mediastinal pseudocyst has not occurred again.

Mediastinal pancreatic pseudocysts are a very rare complication of acute and chronic pancreatitis. Since the first description in 1944 there have been only 55–60 cases reported in the literature. Symptoms are very unspecific and vary from new onset dyspnoea, cough, unspecific thoracic pain, weight loss and dysphagia. Diagnosis is usually made with help of CT, but also with magnetic resonance imaging.1 2 3 4 5 6

The optimal treatment depends on size, surgical and interventional expertise and the severity of symptoms. Until the year 2000, surgical internal drainage was usually performed; CT-guided percutaneous drainage was the alternative treatment.2 6 7 Today endoscopic interventions have become the treatment of choice, because these procedures are minimally invasive and seem to be safe. In principle, the same techniques are used, which are also available for the treatment of abdominal pseudocysts. They include transpapillary nasopancreatic drain placement, transpapillary stent placement in the pancreatic duct and EUS-guided internal drainage achieved by a transgastric or a trans-oesophageal approach.5 6 7 8 Another option could be transgastric retroperitoneal endoscopic debridement, particulary in infected, necrotic pseudocysts, but this has not been performed in the case of a mediastinal pancreatic pseudocyst until now.9 Because of the limited experience so far it is not clear which technique should be preferred.

Although spontaneous resolution under conservative treatment is very rare, it should be considered in stable patients under close supervision.2 3 4

REFERENCES

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Footnotes

  • Robin Spiller, Editor

  • Competing interests None.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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