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Pancreaticopleural Fistula: The Formidable Liaison FREE TO VIEW

Kadambari Vijaykumar, MD; Kevin Dsouza, MD; Kyung Ji, MD; Laurie Lerner, MD
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Rochester General Hospital, Rochester, NY

Chest. 2015;148(4_MeetingAbstracts):875A. doi:10.1378/chest.2246455
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SESSION TITLE: Pulmonary Manifestations of Systemic Disease Student/Resident Case Report Posters I

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Pancreatico- pleural fistulas are relatively uncommon, occurring either as a complication of acute/chronic pancreatitis or after traumatic/surgical disruption of the pancreatic duct. Non-specific chest symptoms often predominate, making it a diagnostic challenge. We present a case of recurrent right pleural effusion secondary to pancreatico- pleural fistula.

CASE PRESENTATION: 52 year old male with history of alcohol induced chronic pancreatitis, pseudocyst formation and recurrent pleural effusion managed with decortication on prior admissions presented with acute worsening dyspnea. He denied cough, sputum, fever/chills or abdominal symptoms. Examination revealed tachycardia, tachypnea and hypoxia requiring a non rebreather mask. He was found to have respiratory failure secondary to recurrent right-sided pleural effusion. Labs revealed leukocytosis and lactic acidosis. Chest radiograph showed right middle lobe infiltrates with a loculated right major fissure pleural effusion which was confirmed on a CT scan (Fig 1). Pleural effusion was initially managed by insertion of a pigtail catheter and antibiotics for pneumonia. The catheter drained copious volume of serous fluid, pleural fluid amylase and lipase were elevated at 62520 and 520200 U/l and a pancreatico-pleural fistula was suspected. MRCP and subsequent ERCP (Fig. 2) demonstrated a large fistulous tract from the main pancreatic duct towards the right pleural space passing postero-laterally towards the right behind vena cava and right liver. Stenting of the pancreatic duct was unsuccessful due to a tight stricture adjacent to opening of the fistula. Conservative management with continued suppression of pancreatic activity was pursued. Following several days of bowel rest and octreotide, his pleural drainage dropped to a minimum and his diet was gradually advanced. Follow- up CT scans of the chest and abdomen showed no reaccumulation of pleural fluid and the catheter was removed. He was discharged on low-fat diet and pancreatic enzyme replacement.

DISCUSSION: The digestive property inherent to pancreatic secretions dissect through the fascial planes forming a communication either anteriorly or posteriorly into the retroperitoneum which then ascends superiorly into the pleural cavity forming a pancreatico pleural fistula. This fistulous track feeds the pleural space with amylase rich secretions. The effusions are typically large and refractory to drainage with tendency to accumulate rapidly.

CONCLUSIONS: Patients with history of pancreatitis or alcoholism with chest symptoms and pleural effusion require a high index of suspicion for pancreatico pleural fistulas. Endoscopic Retrograde Cholangiopancreaticography is the initial investigation of choice. Early restoration of ductal continuity with stenting is essential if conservative management fails.

Reference #1: Ali, Tauseef, Nandakumar Srinivasan, Vu Le, A. Rao Chimpiri, and William M. Tierney. "Pancreaticopleural Fistula." Pancreas 38.1 (2009): E26-31.

DISCLOSURE: The following authors have nothing to disclose: Kadambari Vijaykumar, Kevin Dsouza, Kyung Ji, Laurie Lerner

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