Carlos Figueredo, MD, Tamoor Shahid, MBBS, MD, Hilary I. Hertan, MD, FACG; Montefiore Medical Center, Bronx, NY
Introduction: Pancreaticopleural fistula (PPF) is an uncommon entity. Most cases are related to alcohol-related chronic pancreatitis; being most common in middle-aged individuals. Its diagnosis remains an ongoing challenge given the variety of presentations.
Methods: A 50-year-old female with active alcohol use was admitted for abdominal pain for 10 days followed by a 2-day history of shortness of breath. Physical exam revealed respiratory distress, epigastric tenderness, and absent breath sounds in the left lung. Labs showed mild leukocytosis and elevated lipase of 273 U/L. CT showed a large left pleural effusion and multiple loculated fluid collections within the retroperitoneum around the pancreas. Thoracentesis was performed which showed exudative fluid with lipase of 26,818 U/L and amylase of 8900 U/L , concerning pancreatic pleural effusion. The patient was kept NPO and started on octreotide drip. MRCP revealed pancreas divisum. Pancreatic duct cannulation was tried but failed twice. She was taken to OR later and intraoperative evaluation revealed pancreatic tail inflammation and small fluid collections. She underwent distal pancreatectomy, splenectomy, and cholecystectomy. She did well postoperatively. Discussion: Pancreaticopleural fistula (PPF) is a serious complication of chronic pancreatitis. The estimated incidence is 0.4%. It is type of internal pancreatic fistulas. Fistula forms either because of a leak or rupture of a pseudocyst, or direct PD disruption which if happens posteriorly, resulting in rupture into the pleural cavity to form a PPF. Pleural effusions usually occur on the left (42%–67%), but it is not unusual to find right-sided (19%–40%) or bilateral (14%–17%) effusions. Pleural amylase level measurement is a key step in the diagnosis. An amylase level greater than 1000 U is suggestive of PPF, but malignancy should be ruled out first. CT, ERCP, and MRCP are most widely used in current practice and the sensitivity of each modality in detecting PPF is 47%, 78%, and 80%, respectively. Initial management is conservative with 2-3 weeks of bowel rest and octreotide injections. If this fails, endoscopic intervention is the next step in management. ERCP with pancreatic duct stenting has been reported to be successful in 31-65% of cases whereas surgical intervention is not only curative but highly effective with an 80-90% successful rate if the endoscopic intervention fails. Delay in definitive treatment decreases the chances of a well healing fistula.
ancreaticopleural fistula pre thoracentesis lat view
Pancreaticopleural fistula post thoracentesis
Disclosures: Carlos Figueredo indicated no relevant financial relationships. Tamoor Shahid indicated no relevant financial relationships. Hilary Hertan indicated no relevant financial relationships.