A 55-year-old woman with a history of chronic pancreatitis secondary to alcohol use presented initially with abdominal pain, unintentional weight loss, and progressive fatigue. A computed tomography (CT) scan revealed pancreatic inflammation and a 3-cm pancreatic pseudocyst, which was confirmed on endoscopic ultrasound (EUS), centered near the body of the pancreas.

Two months later, the patient’s symptoms returned despite symptom resolution during the initial hospitalization. In addition to her abdominal pain, the patient presented with hemoptysis and dysphagia. She was readmitted and chest CT identified a well-defined, rapidly expanding fluid collection that extended from the head of the pancreas to the mediastinum ([Fig. 1]). Therapeutic EUS-guided transmural drainage was planned; however, EUS examination revealed arterial flow in the mediastinal segment of the pseudocyst as well as a valve-like structure ([Fig. 2]) connecting the mediastinal and abdominal components of the pseudocyst ([Video 1]). Due to concern that transmural drainage would result in bleeding from vessels within the mediastinal component of the collection, drainage was not performed. Conservative management was pursued and follow-up EUS imaging 6 weeks later revealed diminished size of the pseudocyst.

Mediastinal pancreatic pseudocysts are a rare complication of acute or chronic pancreatitis that have been sporadically reported in case reports [1] [2]. EUS-guided drainage offers a potential treatment option with rapid symptom resolution [3]. Symptom recurrence after endoscopic drainage, however, may prompt surgical intervention. This case highlights a situation in which conservative management may be beneficial, demonstrating the value of EUS and Doppler imaging to determine the safety of endoscopic pseudocyst drainage.

Endoscopy_UCTN_Code_CCL_1AF_2AZ

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Article published online:
18 November 2022

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