P1839 - The Curious Case of Mediastinitis From Severe Necrotizing Pancreatitis

Barbara Mensah, MD, Sara Gottesman, MD, Christoffer Lam, MD, Aditya Desai, MD, Rima Shobar, MD
University of Texas at Austin Dell Medical School, Austin, TX

Introduction: Pancreatitis has a varying range of clinical manifestation, ranging from mild abdominal pain to severe with multi-organ failure and death. In extreme pancreatitis, necrosis occurs leading to further enzymatic destruction which can extend beyond the pancreas . We outline the extra-pancreatic involvement of such necrosis, particularly the erosion into the mediastinum.

Case Description/Methods: A 65- year-old man with a history of heart failure and gallstone pancreatitis presented with dyspnea and peripheral edema, with cardiac etiology ruled out. CT imaging revealed a large right-sided pleural effusion, multiple peri-pancreatic pseudocysts and complex mediastinal fluid collections. A CT scan AP showed an infected walled off fluid collection. He subsequently underwent cystgastrostomy with necrosectomy and eventually underwent a VATS where similar microbacterium was found to have invaded the anterior mediastinum.

Discussion: Necrosis of the pancreas is defined by at least 30% necrosis of the gland. Extra-pancreatic inflammation, although rare, can occur as severity progresses. This is thought to be a cytokine-mediated process whereby inflammatory cells micro-circulate via chemoattraction and molecular adhesion to facilitate their binding to the surrounding endothelium. However, the factors that influence severity remain unclear. In our patient, recurrent pancreatitis resulted in a walled-off pancreatic necrosis that rapidly spread to the anterior and posterior mediastinum. In the rare case of acute mediastinitis from pancreatitis, the mechanism isn’t entirely known but thought to be due to fistula formation resulting in secretions of proteolytic pancreatic enzymes into the mediastinum. In all, gastrointestinal interventions, such as cystogastrostomy for drainage of necrotic pancreatic collections in our patient, is an important therapeutic step.



Disclosures:


Barbara Mensah, MD, Sara Gottesman, MD, Christoffer Lam, MD, Aditya Desai, MD, Rima Shobar, MD. P1839 - The Curious Case of Mediastinitis From Severe Necrotizing Pancreatitis, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.