0036-9330191/04691/146 $1.00 in USA C> 1991 Scottish Medk:aI Journal
Scot Med
J 1991; 36: 146-147
PANCREATIC MEDIASTINAL PSEUDOCYST: REPORT OF TWO CASES SIMULATING INTRATHORACIC DISEASE
N. Ahmad, * CD. Auld, t l.R. Lawrence, * G.D. Watson" Departments of ·Medicine, tSurgery and • • Radiology, Dumfries and Galloway Royal Infirmary, Bankend Road. Dumfries DG 14AP.
Abstract: Mediastinal pseudocysts of the pancreas are extremely rare. Intra-thoracic symptoms such as dysphagia or dyspnoea due to compression or associated pleural effusions are common and urgent decompression by percutaneousor internaldrainage is often necessary. Key words: Mediastinal pseudocyst; chronic pancreatitis. Introduction EDIASTINAL pseudocysts of the pancreas may develop after pancreatitis but are extremely uncommon. They present with a variety of symptoms including dysphagia, vomiting, dyspnoea, chest and abdominal pain. Percutaneous drainage of the cyst helps to relieve the symptoms, although a more definitive surgical procedure is required in the majority of patients. Occasionally spontaneous resolution of the cyst can occur. 1 We wish to report two cases of mediastinal pseudocysts associated with pleural effusions requiring urgent drainage in patients with chronic pancreatitis.
M
Cue I A 44-year-old man with a long history of alcohol abuse. presente~ wi~h intermittent abdominal pain radiating to the back over the preceding SIX months. He had lost weight and complained of mild dysphagia and breathlessness. On admission. there was diffuse abdominal tenderness but no mass was palpable. Moderately elevated serum amylase levels (300-600 iull) were recorded on several occasions during a three-week period. Other investigations included a barium swallow and meal which was normal but chest X-ray showed a small pleural effusion at the left base. Abdominal ultrasound was initially unremarkable. The patient continued to experience increasing symptoms and repeat chest X-ray reveale.d bilateral pleural effusions with a retrocardiac shadow. Some symptomauc improvement followed aspiration of right pleural fluid, the amylase content of which was 4040 iull. cr scan showed an irregular mediastinal fluid collection. extending down through the diaphragm into the abdomen (Fig. 1). The pancreas appeared small and there was a 2 em cyst in the body of the pancreas. It was concluded that the appearance was due to a pseudocyst of the pancreas extending into the mediastinum and communicating with the pleural cavity. Despite a period of total parenteral nutrition and nasogastric suction. the pseudocyst failed to resolve. Serial ultrasounds were performed and
Fla. 1 (a) heart, (b) IVe, (c) Mediastinal pseudocyst, (d) Aorta, (elf) pleural fluid, (g) Gastrografin in gastric fundus. Correspondence to: C.D. Auld. Department of Surgery. Dumfries and Galloway Royal Infirmary. Bankend Road. Dumfries DO 1 4AP.
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ultimately clear evidence of fluid collection under both hemi-diaphragms was obtained. At laparotomy. a dumb-bell shaped collection was found under both hemi-diaphragms communicating with the pancreas via a sinus tract in the lesser sac. The left cystic collection was communicating with the mediastinal cyst via the oesophageal hiatus. Internal drainage was carried out by Roux-en-Y cyst-jejunostomy, following which the patient made an uncomplicated recovery. Repeat ultrasound. prior to discharge. showed no evidence of re-accumulation of fluid. During the subsequent 18 months, this patient has continued to abuse alcohol but. despite this. has remained relatively symptom free.
Cuel A 55-year-old lady, known to suffer from hiatus hernia. coeliac disease and chronic calcific pancreatitis (familial in that a daughter also has chronic pancreatitis). presented with vomiting. abdominal and chest pain over a three-day period. On examination she was moderately dehydrated with upper abdominal tenderness. marked left parasternal pulsation and an ejection systolic murmur. maximal in the left parasternal and pulmonary area. Echo-cardiography revealed. unexpectedly. a small heart with a retrocardiac fluid 'mass' and a huge abdominal fluid collection. Chest X-ray showed bilateral pleural effusions and a plain abdominal X-ray revealed diffuse pancreatic calcification. A barium swallow showed that the lower oesophagus was deviated to the left. apparently being compressed by an adjacent mass and only a small amount of barium entered the stomach (Fig. 2). Repeat X-ray screening showed barium still to be present in the oesophagus after 20 hours. Urgent drainage of pseudocyst was carried out via the left lateral chest wall and an indwelling catheter was placed under ultrasound control. Two litres of dark brown fluid (amylase content 58.000iull) was drained. Serial estimations of serum amylase were within normal limits. Drainage of the fluid was followed by the disappearance of the systolic bruit and considerable improvement in her symptoms with relief of nausea. vomiting and dysphagia. The pleural effusions decreased considerably and the mediastinal fluid collection resolved completely. Repeat barium swallow showed free flow of barium into the stomach. The drain was removed after four days and although some re-accumulation of the fluid in the pancreatic bed (assessed by ultrasound) occurred, it did not extend into the pleural spaces or mediastinum and further drainage was not required. This patient has had episodic back pain related to chronic pancreatitis over the last four years but. as yet. there has been no indication for definitive pancreatic surgery.
Discussion Pancreatic pseudocysts may occur following an attack of acute pancreatitis in approximately 2-5% of cases," In patients with chronic pancreatitis, pseudocysts may develop in a more insidious manner and although usually confined to the lesser sac, may rarely present in unusual sites such as the groin 3 •4 and mediastinum. Since the first reported case in 1944,S approximately 60 cases of mediastinal pseudocyst have been reported in the English literature." The majority of patients have a history of alcohol abuse 1.6- 11 but on admission the clinical features do not necessarily relate to the pancreas and therefore early recognition of the diagnosis may be delayed, A mediastinal pseudocyst has, for example, been discovered by chance as a retrocardiac shadow simulating hiatus hernia or as a posterior mediastinal mass resembling a neurogenic tumour, but, to our knowledge, neither prominent left parasternal pulsation nor cardiac bruit (Case 2) have been reported previously. More commonly, how-
Ahmad, Auld, Lawrence and Watson
although they can rarely resolve spontaneously there is a significant risk of rupture. 13 Surgical procedures which have been employed have included pancreatectomy or pericardectomy though internal drainage of the cyst via an abdominal approach is the treatment of choice. Internal drainage can be carried out either by cystgastrostomy or Roux-en- Y cyst-jejunostomy. Early recognition of mediastinal pseudycysts is important as they may present with a wide range of symptoms varying from those suggestive of oesophageal compression to the involvement of the cardiovascular system and prompt drainage of the cyst leads to immediate symptomatic relief. The most important lesson to be taken from these two cases is that such patients may have symptoms and signs suggestive of a primary introthoracic problem and repeated assessment (as in Case 1) may be necessary before the pancreatic connection can be demonstrated with any real certainty. Factors such as alcohol abuse, pancreatic calcification and amylase content of the pleural fluid may assist greatly in the earlier diagnosis of this rare condition.
'FIg. 2
Lower end of the oesophagus is displaced forward and anteriorly by pancreatic mediastinal pseudocyst.
ever, they are associated with pleural effusions and, on review of the literature, this was found in 53.8% of cases. 12 Barium swallow may show displacement and extrinsic compression of the oesophagus varying with the site of the cyst. In severe cases, there can even be obstruction to the flow of barium into the stomach (Case 2). Ultrasound and cr scan are the key investigations but ERCP is playing an increasing role in the evaluation of such patients. When patients present with severe symptoms such as oesophageal compression, urgent drainage is required. This can be carried out either by draining the pancreas related cyst through the chest wall under ultrasound control or, alternatively, simple aspiration of associated pleural fluid can provide symptomatic relief. Most cases of mediastinal pseudocysts have been treated definitively by surgery and
REFERENCES 1 Serpell JW, Cbristophi C. Mediastinal pancreatic pseudocyst presenting as dysphagia. The Med J of Australia, 1987;146:654-6. 2 Shackelford RT, and Zuidema GO. Surgery of the alimentary tract, pancreas, biliary tract, liver, spleen. W.B. Saunders Co, Philadelphia, 1983, pp 46-54. 3 Salvo AF, Nematolahi H. Distant dissection of a pancreatic pseudocyst into the right groin. Am J Surg, 1973;126:430-432. 4 Alrabeeah AH, Cattral M, Siegenberg J. Unusual presentation of pancreatic pseudocyst: A case report. The Canad J Surg, 1987; 30, 4: 281-282. 5 Jones ES. Pancreatic cysts with report of two unusual cases. J Indiana State Med Assoc, 1944;37: 175. 6 Woods CA, Foutch PG, Waring JP. Sanowski RA. Pancreatic pseudocyst as a cause for secondary achalasia. Gastroenterology, 1989; 96: 235-39. 7 Maier W, Roscher R, Malfertheimer P, Schmidt E, Buchler M. Pancreatic pseudocyst of the mediastinum - Evaluation by CT. EuropJ Radiol, 1986;6: 70-72. 8 Faling U, Gorzof SG, Daly BOT, Pugatcb RD, Snider GL. Treatment of chronic pancreatic pleural effusion by percutaneous catheter drainage of abdominal pseudocyst. Amer J of Medicine, 1984;76: 329-333. 9 Semelka RC, Greenberg HN. Percutaneous drainage of an infected mediastinal pseudocyst. Canad Assoc Radiology, 1987;38: 54-55. 10 Louie S, McGahan JP, Frey C, Cross CEo Pancreatic pleuro-pericardial effusions. Fistulous tracts demonstrated by CT. Arch Int Med, 1985; 145: 1231-1234. 11 Propper DG, Robertson EM. Bayliss AP, Edward N. Abdominal pancreatic pseudocyst - An unusual cause of dysphagia. Postgrad Med J, 1989;65: 329-330. 12 Johnston RH, Owensby LC, Vargas GM, Garcia-Rinaldi R. Pancreatic pseudocyst of the mediastinum. Ann Thorac Surg, 1986; 41: 210-212. 13 Pear B. Pancreatic pseudocyst of the mediastinum. Amer J Radiol, 1980; 134: 1284-1285.
147
Scot Med
J 1991; 36: 146-147
PANCREATIC MEDIASTINAL PSEUDOCYST: REPORT OF TWO CASES SIMULATING INTRATHORACIC DISEASE
N. Ahmad, * CD. Auld, t l.R. Lawrence, * G.D. Watson" Departments of ·Medicine, tSurgery and • • Radiology, Dumfries and Galloway Royal Infirmary, Bankend Road. Dumfries DG 14AP.
Abstract: Mediastinal pseudocysts of the pancreas are extremely rare. Intra-thoracic symptoms such as dysphagia or dyspnoea due to compression or associated pleural effusions are common and urgent decompression by percutaneousor internaldrainage is often necessary. Key words: Mediastinal pseudocyst; chronic pancreatitis. Introduction EDIASTINAL pseudocysts of the pancreas may develop after pancreatitis but are extremely uncommon. They present with a variety of symptoms including dysphagia, vomiting, dyspnoea, chest and abdominal pain. Percutaneous drainage of the cyst helps to relieve the symptoms, although a more definitive surgical procedure is required in the majority of patients. Occasionally spontaneous resolution of the cyst can occur. 1 We wish to report two cases of mediastinal pseudocysts associated with pleural effusions requiring urgent drainage in patients with chronic pancreatitis.
M
Cue I A 44-year-old man with a long history of alcohol abuse. presente~ wi~h intermittent abdominal pain radiating to the back over the preceding SIX months. He had lost weight and complained of mild dysphagia and breathlessness. On admission. there was diffuse abdominal tenderness but no mass was palpable. Moderately elevated serum amylase levels (300-600 iull) were recorded on several occasions during a three-week period. Other investigations included a barium swallow and meal which was normal but chest X-ray showed a small pleural effusion at the left base. Abdominal ultrasound was initially unremarkable. The patient continued to experience increasing symptoms and repeat chest X-ray reveale.d bilateral pleural effusions with a retrocardiac shadow. Some symptomauc improvement followed aspiration of right pleural fluid, the amylase content of which was 4040 iull. cr scan showed an irregular mediastinal fluid collection. extending down through the diaphragm into the abdomen (Fig. 1). The pancreas appeared small and there was a 2 em cyst in the body of the pancreas. It was concluded that the appearance was due to a pseudocyst of the pancreas extending into the mediastinum and communicating with the pleural cavity. Despite a period of total parenteral nutrition and nasogastric suction. the pseudocyst failed to resolve. Serial ultrasounds were performed and
Fla. 1 (a) heart, (b) IVe, (c) Mediastinal pseudocyst, (d) Aorta, (elf) pleural fluid, (g) Gastrografin in gastric fundus. Correspondence to: C.D. Auld. Department of Surgery. Dumfries and Galloway Royal Infirmary. Bankend Road. Dumfries DO 1 4AP.
146
ultimately clear evidence of fluid collection under both hemi-diaphragms was obtained. At laparotomy. a dumb-bell shaped collection was found under both hemi-diaphragms communicating with the pancreas via a sinus tract in the lesser sac. The left cystic collection was communicating with the mediastinal cyst via the oesophageal hiatus. Internal drainage was carried out by Roux-en-Y cyst-jejunostomy, following which the patient made an uncomplicated recovery. Repeat ultrasound. prior to discharge. showed no evidence of re-accumulation of fluid. During the subsequent 18 months, this patient has continued to abuse alcohol but. despite this. has remained relatively symptom free.
Cuel A 55-year-old lady, known to suffer from hiatus hernia. coeliac disease and chronic calcific pancreatitis (familial in that a daughter also has chronic pancreatitis). presented with vomiting. abdominal and chest pain over a three-day period. On examination she was moderately dehydrated with upper abdominal tenderness. marked left parasternal pulsation and an ejection systolic murmur. maximal in the left parasternal and pulmonary area. Echo-cardiography revealed. unexpectedly. a small heart with a retrocardiac fluid 'mass' and a huge abdominal fluid collection. Chest X-ray showed bilateral pleural effusions and a plain abdominal X-ray revealed diffuse pancreatic calcification. A barium swallow showed that the lower oesophagus was deviated to the left. apparently being compressed by an adjacent mass and only a small amount of barium entered the stomach (Fig. 2). Repeat X-ray screening showed barium still to be present in the oesophagus after 20 hours. Urgent drainage of pseudocyst was carried out via the left lateral chest wall and an indwelling catheter was placed under ultrasound control. Two litres of dark brown fluid (amylase content 58.000iull) was drained. Serial estimations of serum amylase were within normal limits. Drainage of the fluid was followed by the disappearance of the systolic bruit and considerable improvement in her symptoms with relief of nausea. vomiting and dysphagia. The pleural effusions decreased considerably and the mediastinal fluid collection resolved completely. Repeat barium swallow showed free flow of barium into the stomach. The drain was removed after four days and although some re-accumulation of the fluid in the pancreatic bed (assessed by ultrasound) occurred, it did not extend into the pleural spaces or mediastinum and further drainage was not required. This patient has had episodic back pain related to chronic pancreatitis over the last four years but. as yet. there has been no indication for definitive pancreatic surgery.
Discussion Pancreatic pseudocysts may occur following an attack of acute pancreatitis in approximately 2-5% of cases," In patients with chronic pancreatitis, pseudocysts may develop in a more insidious manner and although usually confined to the lesser sac, may rarely present in unusual sites such as the groin 3 •4 and mediastinum. Since the first reported case in 1944,S approximately 60 cases of mediastinal pseudocyst have been reported in the English literature." The majority of patients have a history of alcohol abuse 1.6- 11 but on admission the clinical features do not necessarily relate to the pancreas and therefore early recognition of the diagnosis may be delayed, A mediastinal pseudocyst has, for example, been discovered by chance as a retrocardiac shadow simulating hiatus hernia or as a posterior mediastinal mass resembling a neurogenic tumour, but, to our knowledge, neither prominent left parasternal pulsation nor cardiac bruit (Case 2) have been reported previously. More commonly, how-
Ahmad, Auld, Lawrence and Watson
although they can rarely resolve spontaneously there is a significant risk of rupture. 13 Surgical procedures which have been employed have included pancreatectomy or pericardectomy though internal drainage of the cyst via an abdominal approach is the treatment of choice. Internal drainage can be carried out either by cystgastrostomy or Roux-en- Y cyst-jejunostomy. Early recognition of mediastinal pseudycysts is important as they may present with a wide range of symptoms varying from those suggestive of oesophageal compression to the involvement of the cardiovascular system and prompt drainage of the cyst leads to immediate symptomatic relief. The most important lesson to be taken from these two cases is that such patients may have symptoms and signs suggestive of a primary introthoracic problem and repeated assessment (as in Case 1) may be necessary before the pancreatic connection can be demonstrated with any real certainty. Factors such as alcohol abuse, pancreatic calcification and amylase content of the pleural fluid may assist greatly in the earlier diagnosis of this rare condition.
'FIg. 2
Lower end of the oesophagus is displaced forward and anteriorly by pancreatic mediastinal pseudocyst.
ever, they are associated with pleural effusions and, on review of the literature, this was found in 53.8% of cases. 12 Barium swallow may show displacement and extrinsic compression of the oesophagus varying with the site of the cyst. In severe cases, there can even be obstruction to the flow of barium into the stomach (Case 2). Ultrasound and cr scan are the key investigations but ERCP is playing an increasing role in the evaluation of such patients. When patients present with severe symptoms such as oesophageal compression, urgent drainage is required. This can be carried out either by draining the pancreas related cyst through the chest wall under ultrasound control or, alternatively, simple aspiration of associated pleural fluid can provide symptomatic relief. Most cases of mediastinal pseudocysts have been treated definitively by surgery and
REFERENCES 1 Serpell JW, Cbristophi C. Mediastinal pancreatic pseudocyst presenting as dysphagia. The Med J of Australia, 1987;146:654-6. 2 Shackelford RT, and Zuidema GO. Surgery of the alimentary tract, pancreas, biliary tract, liver, spleen. W.B. Saunders Co, Philadelphia, 1983, pp 46-54. 3 Salvo AF, Nematolahi H. Distant dissection of a pancreatic pseudocyst into the right groin. Am J Surg, 1973;126:430-432. 4 Alrabeeah AH, Cattral M, Siegenberg J. Unusual presentation of pancreatic pseudocyst: A case report. The Canad J Surg, 1987; 30, 4: 281-282. 5 Jones ES. Pancreatic cysts with report of two unusual cases. J Indiana State Med Assoc, 1944;37: 175. 6 Woods CA, Foutch PG, Waring JP. Sanowski RA. Pancreatic pseudocyst as a cause for secondary achalasia. Gastroenterology, 1989; 96: 235-39. 7 Maier W, Roscher R, Malfertheimer P, Schmidt E, Buchler M. Pancreatic pseudocyst of the mediastinum - Evaluation by CT. EuropJ Radiol, 1986;6: 70-72. 8 Faling U, Gorzof SG, Daly BOT, Pugatcb RD, Snider GL. Treatment of chronic pancreatic pleural effusion by percutaneous catheter drainage of abdominal pseudocyst. Amer J of Medicine, 1984;76: 329-333. 9 Semelka RC, Greenberg HN. Percutaneous drainage of an infected mediastinal pseudocyst. Canad Assoc Radiology, 1987;38: 54-55. 10 Louie S, McGahan JP, Frey C, Cross CEo Pancreatic pleuro-pericardial effusions. Fistulous tracts demonstrated by CT. Arch Int Med, 1985; 145: 1231-1234. 11 Propper DG, Robertson EM. Bayliss AP, Edward N. Abdominal pancreatic pseudocyst - An unusual cause of dysphagia. Postgrad Med J, 1989;65: 329-330. 12 Johnston RH, Owensby LC, Vargas GM, Garcia-Rinaldi R. Pancreatic pseudocyst of the mediastinum. Ann Thorac Surg, 1986; 41: 210-212. 13 Pear B. Pancreatic pseudocyst of the mediastinum. Amer J Radiol, 1980; 134: 1284-1285.
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