Pneumomediastinum after Endoscopic Transmural Drainage of an Acute Pseudocyst: Not All That Scary!

A 29-year-old man presented with shortness of breath associated with abdominal pain and distension of 2 weeks’ duration. He was diagnosed with alcohol-related acute necrotizing pancreatitis 4 months ago, and computed tomography (CT) done at 3 months of illness revealed a 2.5-cm collection in the neck of the pancreas with dilated upstream main pancreatic duct, suggesting a diagnosis of disconnected pancreatic duct. The investigations done during the current admission revealed hypoxia with amylase-rich exudative ascites (►Fig. 1A) and a large acute pseudocyst (AP) (►Fig. 1B). He underwent endoscopic ultrasound–guided transmural drainage of AP with a fully covered, self-expandable biflanged metal stent (BFMS) (►Fig. 1C). Post drainage, the patient had marked improvement in symptoms but developed palpable subcutaneous emphysema in the neck. CT chest revealed pneumomediastinum (►Fig. 2A; arrows) and CT abdomen revealedmarked reduction in the size of AP, resolution of ascites, and pneumoperitoneum (►Fig. 2B; arrows) along with pneumoretroperitoneum. The patient was treated with intravenous antibiotics, oxygen supplementation, and nasojejunal enteral feeding. The subcutaneous emphysema, tachypnea, and acute lung injury resolved in the following 72hours. Oral feeding was started 7 days later and the BFMSwas replacedwith two 7-Fr double pigtail stents 12 days post drainage. Thereafter, the patient was discharged and is currently asymptomatic.