Janine Beatrice G. Borja
A 51-year-old male with history of alcohol-induced pancreatitis presented with 3-day dyspnea and left-sided chest pain. BP 130/88, HR 140, 88% saturation, afebrile with a benign abdomen on exam. Labs showed WBC 27, pH 7.28, pCO2 38, bicarbonate 18, lactate 6.7, and lipase 957. CTPA showed left lower lobe consolidation and a large pleural effusion. He was given antibiotics, and admitted to ICU for respiratory failure. Chest tube had purulent drainage that later grew S. viridans. It continued to drain >500 mL output daily. CT showed left basilar pleural fluid collection with abscess extending down the pancreatic tail, likely originating as an infected pancreatic pseudocyst. Pleural fluid amylase was 3,261 with lipase >12,000.
Cardiothoracic surgery was consulted, and an intrapleural pigtail catheter was inserted. MRCP showed two peripancreatic pseudocysts adjacent to the pancreatic tail with one collection communicating with the pleural effusion. EGD with EUS-guided fine needle aspiration of the cyst was done, not amenable to cystogastrostomy. Somatostatin was given with marked reduction in output. He ultimately underwent ERCP with pancreatic duct stent placement.
Pancreaticopleural fistula (PPF) occurs in 0.4% of chronic pancreatitis, and arises from disruption of pancreatic ducts. Since symptoms are mainly pulmonary, diagnosis may be delayed up to an average of 5 weeks. Checking for pleural fluid amylase is key. There is no established cut-off value, but usually it is >10,000 U/L. This should be differentiated from exudate associated with acute pancreatitis that is less severe. CT, ERCP and MRCP have diagnostic sensitivities of 47%, 78%, and 80%, respectively. MRCP is the imaging of choice as it can visualize a fistula beyond strictures, pancreatic ductal structural changes, and small pseudocysts.
Treatment may be medical, endoscopic, and/or surgical. No controlled trials have been conducted due to its rarity. In the advent of somatostatin, treatment can be continued for 2.5–6 months and chest drainage for 6–24 days. Success rate of medical management alone has been 31-65%, but it is recommended only for a normal or mildly dilated pancreatic duct with no strictures. Those with disruptions in the ducts should undergo ERCP, whereas surgery is necessary in those with complete ductal obstruction, or if stenting will be difficult to achieve.
Initial chest CT showing extensive left lower lobe consolidation and a moderate-to-large loculated left pleural effusion.
MRCP revealing two peripancreatic fluid collections adjacent to the tail of the pancreas representing pseudocysts. The more superior collection
communicates with the left pleural effusion.
Chest CT showing a moderate-sized complex left basilar pleural fluid collection/empyema with atelectasis of most of the left lower lobe. This fluid collection is noted to be continuous at the diaphragm with an irregular fluid collection/abscess in the left upper quadrant extending down to the
tail of the pancreas, possibly originating as an infected pancreatic pseudocyst.
Janine Beatrice Borja indicated no relevant financial relationships.
Altaf Dawood indicated no relevant financial relationships.
Mario Affinati indicated no relevant financial relationships.
Nicole Gentile indicated no relevant financial relationships.
Jagpal Sahota indicated no relevant financial relationships.