Grace E. Kim, MD1, David Lo, MD, FACG2
1University of Maryland Medical Center, Baltimore, MD; 2Ohio Gastroenterology Group, Inc., Columbus, OH
Introduction: Pseudocysts (PC) are well-known complications of acute and chronic pancreatitis. Symptoms can include abdominal pain, early satiety and weight loss. We present a unique case of a PC presenting with dysphagia.
Case Description/Methods: A 47-year-old female with history of acute on chronic pancreatitis due to alcoholism complicated by a persistent PC presented with weight loss and progressively worsening dysphagia for one year. Prior attempted surgical cystgastrostomy and percutaneous aspiration of her PC were unsuccessful. Esophagram showed a stricture of the distal esophagus, without passage of a barium tablet, and computed tomography and magnetic resonance imaging demonstrated a 6x5.3cm PC compressing the distal esophagus (Figure 1). Esophagogastroduodenoscopy with balloon dilation was not efficacious. Endoscopic ultrasound cystgastrostomy was attempted but not feasible due to the proximal location of the PC. Endoscopic retrograde cholangiopancreatography (ERCP) was consistent with severe chronic pancreatitis by Cambridge classification; there was a high-grade stricture at the genu with upstream pancreatic duct (PD) dilation and communication with the PC. The stricture would only allow dilation initially with a 5-4-3 cannula, which allowed placement of a 5-French PD stent to bridge the stricture, and a 10-French double pigtail stent for transpapillary drainage of the pseudocyst (Figure 2). Stricture brushings were negative for malignancy. Her dysphagia resolved with resulting weight gain, and subsequent ERCPs (with serial PD stenting to 10-French) demonstrated resolution of her PC and PD stricture.
Discussion: Dysphagia due to PC has been rarely reported. It is usually due to mediastinal extension of a PC, which has been treated by endoscopic (e.g. transpapillary and transmural drainage), radiologic, and surgical means with good technical success1,2. In our case, due to the proximal position of the PC which prohibited transmural drainage, along with failure of prior surgery and percutaneous aspiration, transpapillary drainage was necessary and effective. Resolution of the inciting PD stricture by stenting was of paramount importance for the prevention of PC recurrence.
Citation: Grace E. Kim, MD; David Lo, MD, FACG. P1499 - TRANSPAPILLARY DRAINAGE OF PERSISTENT PSEUDOCYST CAUSING DYSPHAGIA. Program No. P1499. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.