View Abstract

A6655 - Pancreaticopleural Fistulae; a Rare Pulmonary Complication of an Intra-Abdominal Disease
Author Block: M. Antoine1, B. Sharma2, D. Markabawi1, P. Kopparthy1; 1Internal Medicine, SUNY Upstate Medical University, Syracuse, NY, United States, 2SUNY Upstate Medical University, Syracuse, NY, United States.
Introduction:
Pancreaticopleural fistulae are rare pulmonary complications with an incidence of 3 to 7 % reported in patients with chronic pancreatitis. It is characterized by massive pleural effusion from continuous pancreatic secretions draining directly into the pleural cavity through an abnormal tract. We present the case of a pancreaticopleural fistula in a man with alcohol chronic pancreatitis who presented with chest pain and recurrent pleural effusion.
Case report:
59-year-old male with medical history of chronic pancreatitis and pancreatic pseudocyst presented with chest pain and shortness of breath. Six weeks previously he was managed for an infected pancreatic pseudocyst with a course of antibiotics. Shortly following this treatment, he presented to the hospital with shortness of breath and left sided chest pain and was found to have a massive left sided pleural effusion, which was managed with a tube thoracostomy. Initial workup was directed toward finding a thoracic pathology. Fluid was exudative but microbiology and cytology were both negative. A computed tomography (CT) did not show evidence of malignancy in the thorax. In the abdomen, it showed an enlarging pseudocyst and post-stenotic dilatation of the pancreatic duct. Two weeks after discharge, he returned with recurrent massive left-sided pleural effusion. In view of recently infected pseudocyst, pleural fluid amylase was requested at the time of drainage and came back at 6,102 U/L and lipase at 19,279 U/L. A Magnetic Resonance Cholangiopancreatography (MRCP) showed fistulous connection between main pancreatic duct and pleural space. Octreotide was started at 50 mcg intravenously TID. He remained on this regimen for 6 weeks. Stent placement not attempted since patient was improving. Chest tube removed once fluid drainage decreased to an acceptable level. He was seen in the clinic 2 months later and was doing well. Follow-up MRCP showed resolution of the tract.
Discussion:
Pancreaticopleural fistula is a rare complication of chronic pancreatitis and must be considered in the evaluation of an unexplained recurrent pleural effusion in patients with chronic pancreatitis. It can be difficult to diagnose seeing that the predominant symptoms are thoracic rather than abdominal. Modalities such as MRCP offered more sensitivity than CT scan. Guidance in management is largely based on small case series. Current recommendation supports conservative management with infusion with/without stent placement for at least 4-6 weeks. Failure of medical treatment is an indication for surgical treatment but there is limited data regarding timing of invasive management.