Dysphagia Due to a Cystic Mediastinal Mass
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CLINICAL CONUNDRUM
Dysphagia Due to a Cystic Mediastinal Mass Wolfgang Pumberger • Beate Maier-Hiebl Simon Kargl
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Received: 5 November 2012 / Accepted: 6 December 2012 / Published online: 1 January 2013 Ó Springer Science+Business Media New York 2012
Clinical Conundrum A previously healthy 2-year-old boy was referred because of progressive vomiting and diarrhea, which were initially interpreted as a gastrointestinal infection. The symptoms started about 10 days before the patient presented at our department and had worsened in the last two days. The boy developed progressive dysphagia which advanced to where he was unable to swallow his own saliva. Physical examination and laboratory investigations showed no abnormal findings. Specifically, no mass was found on examination of the abdomen. A contrast study of the esophagus showed a complete stop in the third portion of the esophagus. The latter revealed hyperperistalsis mimicking some kind of resistance (Fig. 1a, b). Because of a vague episode of foreign body impaction, we performed an endoscopic examination of the upper gastrointestinal tract under general anesthesia. The endoscopic investigation showed no signs of foreign body impaction but did reveal a submucosal tumor in the distal portion of the esophagus. A bluish, gleaming, soft swelling led to almost complete narrowing of the esophagus, with no visible ulceration of mucosa or communication with the lumen (Fig. 2a). Surprisingly, we were able to pass through the constriction with no difficulty. The tumor extended into the stomach and was seen as a swelling at the
W. Pumberger S. Kargl (&) Department of Pediatric Surgery, Women’s and Children’s Hospital Linz, Krankenhausstraße 26-30, 4020 Linz, Austria e-mail: [email protected]; [email protected] B. Maier-Hiebl Department of Pediatric Radiology, Women’s and Children’s Hospital Linz, Linz, Austria
fundus (Fig. 2b). The rest of the stomach and the duodenum were normal. A subsequent ultrasound examination revealed a dumbbell-shaped cystic lesion in the patient’s right thoracic cavity, passing through the diaphragm and in close contact with the wall of the stomach (Fig. 3). The cyst was filled with hyperdense material and the distal esophagus could not be outlined. The mass had led to displacement of the vena cava inferior and the confluence of the liver veins. An MRI was performed to obtain more information about the mass and its relationship to adjacent structures. The investigation showed the cystic lesion at the right lower mediastinum, next to the spine, extending into the abdominal cavity with close contact between the cyst and the wall of the esophagus and the stomach (Fig. 4).
What is the likely diagnosis? The investigations confirmed the diagnosis of a thoracoabdominal duplication cyst, and we decided to perform surgery. A wide abdominal access revealed a dumbbellshaped, smooth-walled cyst extending from the fundus of the stomach through the diaphragm into the posterior mediastinum. The mass comprised muscular layers of the intra-abdominal
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