1318 Pancreaticopleural Fistula in a Patient With Recurrent Alcoholic Pancreatitis: Combined Endoscopic and Medical Management

Abstract

INTRODUCTION: Pancreaticopleural fistula (PPF) is a rare complication of pancreatitis, resulting from disruption of the pancreatic duct. This injury may be secondary to acute/chronic pancreatitis, trauma, or surgery. Here we describe a patient with a PPF, and our workup and treatment for this rare condition. CASE DESCRIPTION/METHODS: A 61-year-old male with COPD, alcohol misuse, and history of recurrent acute alcoholic pancreatitis complicated by pseudocysts was admitted with one month of worsening shortness of breath from a large left pleural effusion, which reaccumulated within four days after a 1.6 L thoracentesis. On examination he had mild abdominal tenderness in the RUQ and epigastrium. Labs were notable for serum amylase 1105 U/L, lipase >1000 U/L, and WBC 10.8. He underwent another thoracentesis, removing 1.5 L of fluid which was an exudate with amylase greater than 2000 U/L. CT of the chest and abdomen showed a subdiaphragmatic LUQ fluid collection with communication to the pancreatic body and duct. A chest tube was then placed to prevent fluid re-accumulation. MRCP confirmed a PPF from the proximal pancreatic body duct to the left pleura. He was started on octreotide. ERCP confirmed a fistula originating from the distal pancreatic duct but attempts to pass a wire into the dorsal pancreatic duct were unsuccessful, and a ventral pancreatic sphincterotomy was performed. His chest tube was removed after one day, and he was discharged to continue octreotide at home. Unfortunately, he returned the following day with complaints of dyspnea. Pancrelipase was then added in an attempt to minimize pancreatic exocrine secretions. On follow-up 1 and 2 months later, the pleural fluid is much smaller, and the patient's dyspnea has resolved. DISCUSSION: Here we present a novel management of PPF without pancreatic duct stent placement and instead with pancreatic sphincterotomy to divert pancreatic secretions away from the fistula tract and medical therapy (octreotide and pancrelipase) to reduce the pancreatic secretion. The diagnosis was reached through a combination of clinical history, lab studies (particularly, the elevated amylase in the pleural fluid), and CT and MR imaging. This was further confirmed with ERCP, which is useful especially if a stent can be placed to divert secretions away from fistula tract. Ultimately, this diagnosis requires a high index of suspicion, particularly in patients who present with recurrent effusions in the setting of pancreatitis.