Sandy Chan, MD, Matthew Petersile, MD, Jaroslav Zivny, MD; UMass Memorial Medical Center, Worcester, MA
Introduction: Pancreatic fistulas are rare complications of chronic pancreatitis, typically caused when disruption of the pancreatic duct causes leakage of pancreatic fluid that erodes through neighboring organs and structures. Pancreaticopleural and pancreaticopericardial fistulas are extremely rare and management of these fluid collections is challenging with no consensus described in the current literature. We present a case of a patient with concurrent pancreaticopericardial and pancreaticopleural fistulas who improved with endoscopic management.
Methods: A 53-year-old female with a history of chronic pancreatitis complicated by pseudocysts presented with abdominal pain, shortness of breath, nausea and vomiting. Initial lab work was unremarkable. CT scan of the chest and abdomen showed a new large pericardial and new large right sided pleural effusion. A stat echocardiogram revealed cardiac tamponade and urgent pericardiocentesis was performed. Fluid studies showed an elevated lipase suggesting possible communication between the fluid collections and pancreas. Thoracentesis was unsuccessful due to the high fluid viscosity. Further review of the CT scans revealed concern for a pancreaticopleural and pancreaticopericardial fistula. The surgery team declined operative intervention citing a concern that without endoscopic drainage the effusions may reaccumulate. An ERCP was performed with fluoroscopic images demonstrating a fistula tracking from the main pancreatic duct into the mediastinum. A plastic stent was placed in the pancreatic duct to allow for drainage. A repeat CT Chest one week after ERCP showed significant improvement in pleural effusion without additional intervention. Repeat ERCP four weeks after initial ERCP showed no contrast extravasation out of the pancreas suggesting resolution of the fistulas. Discussion: Pancreaticopleural and pancreaticopericardial fistulas are rare and their management is not well defined. Prior case reports have focused on externally draining the fluid collections with a few cases of endoscopic management described. Fistulous tracts that are bridged endoscopically with stents have a healing rate of over 90%. However, the fistula in our patient closed with pancreatic duct drainage only despite the fact that the fistulous tract was unable to be stented. Our case demonstrates that appropriate endoscopic drainage can be a viable therapy and should be considered in the management of pancreaticopleural and pancreaticopericardial fistulas.
Disclosures: Sandy Chan indicated no relevant financial relationships. Matthew Petersile indicated no relevant financial relationships. Jaroslav Zivny indicated no relevant financial relationships.