View Abstract

A3243 - Pancreaticopleural Fistula: An Obscure Case of Right-Sided Pleural Effusion
Author Block: R. A. D. Wilson1, H. R. Sequeira2, R. Scatena2; 1Internal Medicine, Norwalk Hospital/Yale University, Norwalk, CT, United States, 2Pulmonary Critical Care Medicine, Norwalk Hospital/Yale University, Norwalk, CT, United States.
Pancreaticopleural fistula (PPF) is a rare complication of pancreatitis caused by disruption of the pancreatic duct and leakage of secretions into the pleural cavity. Pleural effusions occur via the fistulous connection or direct extension of a pancreatic pseudocyst into the pleural space. The effusion is typically exudative and left-sided but may manifest bilaterally or on the right side.
A 57-year-old male with history of alcohol abuse presented with 2 weeks of progressive right-sided chest, neck and shoulder pain after recent travel. He denied fevers, chills, cough and shortness of breath. He was afebrile and hemodynamically stable. There were decreased breath sounds at the right base with a corresponding effusion on CXR. CT scan demonstrated a right-sided pleural effusion extending superiorly from a multi-loculated cystic collection deep to the fibers of the right diaphragmatic crus. The pancreas was diffusely atrophic with several intraparenchymal calcifications, and moderate dilatation throughout the main pancreatic duct was also noted. Labs were remarkable for serum lipase of 435 U/L. A right-sided thoracentesis was performed for 1L of exudative fluid with amylase of 3023 U/L. He was discharged to the care of his primary gastroenterologist for further management, including possible ERCP and stent placement.
PPF is a rare cause of pleural effusion occurring in 0.4-7% of pancreatitis1, and chronic alcoholism is the major risk factor for pancreatitis leading to PPF formation2. Pancreatic pseudocyst is identified in 69-77% of cases2. Dyspnea is the most common presenting symptom3, and patients rarely complain of abdominal pain, which may delay diagnosis. Exudative pleural fluid with elevated amylase >1000 U/L is suggestive4, and recurrent effusions in a patient with pancreatitis should raise suspicion for PPF5. MRCP may identify the fistula and characterize the underlying pancreatic pathology with better sensitivity compared to CT2.
Immediate treatment involves symptom management with therapeutic thoracentesis. Given the likelihood of recurrent effusion, the underlying PPF must be addressed. Indwelling pleural catheter is not recommended given risk for malnutrition, dehydration and electrolyte abnormalities. Somatostatin analogues may reduce fistula output by suppressing pancreatic exocrine function but it is unclear if they improve closure rates4, 7. ERCP with stent placement is the mainstay of therapy for PPFs as it promotes internal drainage by relieving defects of the pancreatic duct, thereby reducing flow through the fistula tract6. If pleural effusion recurs or if stenting is not feasible, surgical intervention for pancreatic ductal decompression should be considered.