Pseudocyst of pancreas with mediastinal extension

Case contributed by Dr Prashant Mudgal


Pain in epigastrium for past 10 days.

Patient Data

Age: 55 years
Gender: Female

There is large, low attenuation, thick (2-5 mm) and irregular walled multiloculated cystic peripherally enhancing lesion with thick internal septae, measuring approximately 6.2 x 4.6 x 4.3 cm noted adjacent to the pancreatic head  and body.
The lesion is abutting the left lobe of liver anteriorly, porta hepatis right laterally, spleno-mesenteric confluence inferioly and hepatic artery, portal vein and IVC posteriorly with intact fat planes.
The fat plane between pancreas and the lesion appears obliterated.
The pancreas shows normal lobulations and contours. There is no evidence of any pancreatic calcification or ductal dilatation.
A similar low attenuating thick walled peripherally enhancing cystic lesion, measuring approxmately 5.2 x 2.8 cm noted in the lower aspect of posterior mediastinum and appears to arise adjacent to the esophageal hiatus and extending up to the carina. 

Large, low attenuation, multiloculated cystic peripherally enhancing peripancreatic lesion with image morphology and extension as described above with a similar lesion in the posterior mediastinum arising adjacent to the esophageal hiatus of diaphragm; most likely suggest chronic pancreatic pseudocyst with mediastinal pseudocyst.

Case Discussion

Mediastinal extension of pseudocyst is a rare complication of acute or chronic pancreatitis. The inflammatory fluid can gain into mediastinum through diaphragmatic hiatus (esophageal or aortic) or directly through the diaphragm, later the fluid gets organize to form a pseudocyst in the posterior mediastinum.

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