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A6671 - Pancreatico-Pleural Fistula Presenting with Large Right-Sided Pleural Effusion
Author Block: D. Prime1, A. Singh2, M. J. Rosen1; 1Pulmonary Critical Care and Sleep Medicine, Mount Sinai St. Luke's West, New York, NY, United States, 2Internal Medicine, Mount Sinai St. Luke's West, New York, NY, United States.
Introduction: Pancreatico-pleural fistula (PPF) is a rare complication of pancreatitis. Pancreatitis, pancreatic trauma and surgical disruption of the pancreatic duct are the most common causes of PPF. We describe a patient with pancreatitis and right-sided pleural effusion (PE) from PPF. Case description: A 45-year-old woman was admitted with acute pancreatitis and dyspnea; chest radiograph showed large, right-sided PE, and computerized tomography (CT) of chest and upper abdomen revealed right, loculated PE, with right middle and lower lobe collapse. A pancreatic pseudocyst was found extending superiorly from the pancreatic body through the diaphragmatic hiatus into the posterior mediastinum and was contiguous with the effusion. Ultrasound-guided thoracentesis removed 1500ml of amber-colored fluid with fluid analysis revealing lymphocyte-predominant exudate, fluid amylase level of 8773U/L and negative cultures. The patient was discharged with recurrence of the right-sided pleural effusion after 4 weeks. Magnetic resonance imaging of the abdomen with cholangiogram demonstrated the multi-loculated pseudocyst, extending by means of multiple tracts into the retroperitoneum and mediastinum with large right effusion. Video assisted thoracoscopy was performed, evacuating 2 liters of bilious fluid. The diaphragm appeared intact. A tunneled pleural catheter and 28F Blake drain were placed after decortications and washout. Endoscopic retrograde cholangiopancreatography (ERCP) showed stricture in the main pancreatic duct, pseudocyst in the area of the body and tail and probable pancreatic duct disruption. Sphincterotomy was performed and the ventral pancreatic duct was stented. After multidisciplinary discussion with thoracic surgery and gastroenterology she was discharged without surgical intervention. Discussion: Pleural effusions occur in 3 to 17% of cases of pancreatitis. PPF is rare, occurring in about 3% of patients with pancreatic pseudocyst and generally presents with recurring effusions in patients with chronic pancreatitis. Effusions usually form through a natural hiatus or directly through the dome of diaphragm. Diagnosis of PPF is a diagnostic challenge. ERCP is frequently used to demonstrate a fistulous tract between the pancreas and the pleural space, but is not always diagnostic. In our patient, evidence of fistulous tract was never shown but the history of acute pancreatitis, imaging showing pancreatic disruption and pleural fluid analysis showing elevated amylase was enough to establish the diagnosis of PPF. Conservative management, with bowel rest and repeated thoracentesis, has been found to have a success rate of 40 to 60% however there is high likelihood of recurrence. Operative management allows for a success rate of 94%, compared to 31% with medical therapy.