Pseudocyst of the pancreas masquerading as spontaneous pneumomediastinum

Abstract

Pseudocyst of the pancreas extending into the thorax represents a rare but potentially catastrophic diagnosis. It can be difficult to both diagnose and manage, with only limited management suggestions within the literature. While pleural effusion is a common complication of pancreatitis, transthoracic extension of a pseudocyst is a rare phenomenon. Herein we discuss a patient with a difficult to recognize extension of pancreatic pseudocyst into the left hemithorax, with unique imaging findings. He had good response to trans-gastric and percutaneous drainage and ultimately proceeded to thoracotomy and decortication. Around this case, the options for investigation and management are discussed.

Figure 1:

Chest X-ray prior to transgastric drainage. Suggestive of Left pleural effusion/ lower lobe collapse.

Figure 2:

Chest X-ray post-transgastric drainage. Area of residual space highlighted with arrows.

Figure 3:

Sagittal view CT Chest revealing large residual space with loss of left lung volume due to the pseudocyst. Image post-transgastric drainage.

Figure 4:

Area of communication between the drained Pseudocyst and the Left Pleura. Space noted with arrow.

Figure 5:

Sagittal view CT Chest post-intercostal catheter drainage of the Pancreatico-pleural fistula. Smaller residual space can be noted compared to Image 3, with some ongoing loss of lung volume and small fluid collection.

Figure 6:

CT one month post-decortication with complete re-expansion of the left lung and minor post-operative changes noted posteriorly.