SESSION TYPE: Pleural Student/Resident Case Report Posters
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: Pancreaticopleural fistulas are known, however unusual complications of chronic pancreatitis. A right-sided tension hemothorax with an elevated pleural amylase level is an extremely rare finding, and in this case was associated with a pancreaticopleural fistula involving a pancreatic pseudocyst with splenic artery erosion and subsequent pseudoaneurysm formation.
CASE PRESENTATION: We present a case of a 42-year-old alcoholic man with a longstanding history of chronic pancreatitis with known pseudocysts, previously on TPN, who presented to our Emergency Department with complaints of right pleuritic chest pain, progressive and severe dyspnea on exertion, and anorexia. Physical examination revealed a pale man in mild respiratory distress and absent breath sounds over the right chest. CT chest revealed radiologic evidence of tension—massive right pleural effusion with contralateral mediastinal shift. CT abdomen showed chronic pancreatitis and two pseudocysts with the larger in the head and other in the tail. Initial labs were pertinent for hemoglobin 7.7, WBC 13.9 and lipase 88. Thoracentesis revealed frank dark blood, which clotted easily upon evacuation. Pleural fluid analysis was notable for RBC 1690K; amylase 8991; negative cytology; and negative cultures. A chest tube was placed, draining a total of 8.3 liters of blood over a course of two days. MRCP revealed a large fistulous tract formation between the pseudocyst in the tail of the pancreas and the right pleura. Subsequent angiography confirmed a tamponaded splenic artery pseudoaneurysm adjacent to the pancreaticopleural fistula. It was felt that the pancreaticopleural fistula had eroded into the splenic artery, leading to the massive tension hemothorax. After a prolonged hospitalization, the pleural space was completely evacuated and the chest tube was removed. An IR guided splenic artery stent was placed to prevent further life threatening hemorrhage. Subsequent imaging showed gradual reduction in size of the fistula.
DISCUSSION: Chronic pancreatitis results in inflammation leading to stricturing of the pancreatic duct, pseudocyst formation, further erosion, and pancreatic fistula formation. Subsequent leakage of exocrine secretions cephalad through openings in the diaphragm results in thoracopancreatic fistulas. There are very few case reports and series on pancreaticopleural fistulas and almost all reports show left-sided pleural effusions, most likely due to proximity. Pleural amylase level > 5 x serum level is suggestive of a pancreaticopleural fistula. Erosion of the fistula into neighboring vascular structures can lead to fatal consequences.
CONCLUSIONS: To our knowledge, we present the only case report documented of a pancreaticopleural fistula with splenic artery erosion leading to a massive right-sided tension hemothorax.
1) Sahn, Steven. Pleural Effusions of Extravascular Origin. Clin Chest Med 27 (2006) 285-308.
DISCLOSURE: The following authors have nothing to disclose: Lynell Newmarch, Angela Mayorga, Nancy Lee, Yasmeen Kabir, Arin Aboulian, Nader Kamangar
No Product/Research Disclosure InformationUCLA-Olive View Medical Center, Los Angeles, CA