Esophageal stricture following successful resolution of a mediastinal pseudocyst by endoscopic transpapillary drainage

A 42-year-old alcoholic man had recurrent upper abdominal pain accompanied by breathlessness and right-side pleuritic chest pain for 5 months. Examination revealed right-sided pleural effusion. He had normal hemogram, liver, and renal function tests, normal serum amylase and a normal calcium profile. Thoracentesis from the right-sided pleural effusion revealed no cells, a high protein content (4.3g/dL), and elevated amylase (2800IU/L). Tube drainage of the right pleural effusion was done; it continued to drain 200–400mL/day of clear fluid with a high amylase content. A contrast-enhanced computed tomography (CECT) scan of the chest and abdomen showed a small abdominal pseudocyst (pancreatic pseudocyst), right-sided pleural effusion, and a 5-cm pseudocyst in the posterior mediastinum compressing the lower end of the esophagus with its proximal dilatation (●" Fig.1). Endoscopic ultrasound (EUS) revealed features of chronic noncalcific pancreatitis along with a mediastinal pseudocyst that was displacing the descending aorta posteriorly (●" Fig.2). Endoscopic retrograde cholangiopancreatography (ERCP) was performed. Contrast-free deep cannulation of the pancreatic duct was achieved (●" Fig.3), and a 5-Fr pancreatic stent was placed. The patient had marked improvement in his symptoms, with resolution of abdominal pain and cessation of chest tube drainage within 2 weeks of stent insertion. The chest tube was removed, and repeat CECT of the chest and abdomen at 4 weeks showed resolution of all the pseudocysts and pleural effusion. However, the patient started complaining of dysphagia to solids, which gradually worsened. Endoscopy revealed a nonnegotiable stricture at the lower end of the esophagus. EUS with a radial echoendoscope from the mouth of the stricture revealed thickening of the esophageal wall with loss of the layered pattern of the esophageal wall (●" Fig.4). Endoscopic dilation was performed with bougie dilators, and the stricture was gradually dilated up to 15mm in diameter. With this, therewasmarked improvement in the paFig.1 Contrastenhanced computed tomography (CECT): mediastinal pseudocyst (white arrows) compressing the esophagus with its proximal dilatation (arrow heads). Also note the right-side pleural effusion (stars) with intercostal draining tube in situ.