A Case Report of Pancreaticopleural Fistula That was Treated Conservatively

Abstract

Introduction: Pancreaticopleural fistula(PPF) is a rare complication of pancreatitis. It has been reported to occur in about 0.4% cases of pancreatitis mainly in chronic cases. It's defined as an abnormal connection between the pancreas and the adjacent pleural cavity. It's difficult to demonstrate the fistula tract on imaging like CT or MRCP but amylase-rich pleural fluid (greater than the upper limits of normal for serum amylase) is highly suggestive of the diagnosis. There's no guidelines for treatment and we are presenting a case of PPF that was treated conservatively. Case Report: 49-year-old female with a past medical history of alcoholic pancreatitis who presented with worsening dyspnea, orthopnea and right-sided chest pain. She had been recently admitted for an episode of alcoholic pancreatitis 4 weeks ago. Patient was found to be tachypneic, tachycardic and with no breath sounds on the ride side of the chest. Labs were notable for a leukocytosis of 19.1 and lipase 16,232. CXR showed a white-out of the right hemithorax (Fig. 1). CT abdomen and pelvis showed multiple subdiaphramatic fluid collections, atrophic pancreas and no significant PD dilation. 9 liters of fluid was drained and fluid analysis showed an amylase of >50,000. PPF diagnosis was made and she was started on octreotide drip and kept NPO on TPN. Patient had multiple ERCPs, but Pancreatic duct (PD) cannulation/stenting was unsuccessful despite using different sphincterotomes and wires. Patient remained asymptomatic and eventually started on diet which she tolerated well. Repeat CT prior to discharge showed partially loculated right pleural effusion and interval decrease of fluids collection in the upper abdomen (Fig. 2). Patient was followed closely after discharged.3 months after her presentation, she remains asymptomatic, repeat images (Fig. 4). showed stable loculated pleural effusion and no intervention is planned.FigureFigureConclusion: Pancreaticopleural fistula is a serious complication of acute or chronic pancreatitis. Modalities of treatment are endoscopic stenting of the disrupted PD, conservative management with octreotide and chest tube drainage for extended period, or surgical intervention. We present a case who has been successfully treated with a limited period of octreotide and no indwelling chest drain.This supports the prior limited data that interventions may not be needed for PPF especially in case of loculated effusion and no evidence of PD disruption.Figure