A RARE CASE OF EMPYEMA SECONDARY TO PANCREATICOPLEURAL FISTULA

Abstract

SESSION TITLE: Medical Student/Resident Disorders of the Pleura Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pancreaticopleural fistula is a rare complication of pancreatitis resulting from pancreatic duct disruption with leakage of pancreatic secretions into the pleural cavity. CASE PRESENTATION: 50-year-old woman with alcohol use disorder and chronic pancreatitis presented with abdominal pain, vomiting and dyspnea on exertion. Serum chemistries revealed elevated lipase and amylase suggesting acute pancreatitis. Computer Tomography (CT) chest, abdomen and pelvis revealed massive left pleural effusion causing mediastinal shift to the right and multiple rim-enhancing cystic structures around the pancreas, suggestive of pancreatic pseudocysts. Pleural drainage was performed with a chest tube placement, after which patient reported symptom relief. Pleural fluid analysis revealed an exudative pattern with elevated amylase, reflecting likely pancreatic etiology, and raising suspicion of pancreaticopleural fistula (PPF). Following pleural fluid drainage and aeration of the lung, she developed fever with leukocytosis; repeat CT chest revealed multi-loculated pleural effusion. A working diagnosis of empyema secondary to (PPF) was made and patient was started on intravenous (IV) antibiotics. Magnetic resonance cholangiopancreatography (MRCP) revealed walled off necrosis surrounding the pancreatic tail extending into the left subdiaphragmatic and left pleural spaces, confirming the diagnosis of (PPF). She underwent Endoscopic retrograde cholangiopancreatography (ERCP) without successful cannulation of pancreatic duct. Partial distal pancreatectomy was performed with resolution of pleural effusion and symptoms. DISCUSSION: PPF is usually a consequence of leak from an incompletely formed or ruptured pseudocyst or from direct pancreatic duct leak either through the esophageal hiatus or the diaphragm into the pleural space. It typically presents with pulmonary symptoms more than the abdominal symptoms. Left-sided pleural effusion is typical, though right-sided or bilateral effusions are not uncommon. Empyema, a known major complication that can lead to life threatening sepsis, occurs when there is an ascending infection via the fistulous tract. Diagnosis is based on clinical suspicion; elevated amylase in pleural fluid strongly supports the diagnosis. MRCP is a useful diagnostic modality demonstrating the fistula. Initial management consists of pleural drainage and tube thoracotomy placement. Minimally invasive thoracic surgery with pleural debridement can also be considered. Definitive management of fistula is accomplished with stent placement via ERCP, though if that fails, surgical intervention with pancreatectomy is considered, as described in our case. CONCLUSIONS: A high index of clinical suspicion is needed for diagnosis of PPF in patients presenting with dyspnea and history of pancreatitis or its risk factors Reference #1: Schweigert M, Renz M, Dubecz A, Solymosi N, Ofner D, Stein HJ. Pancreaticopleural fistula-induced empyema thoracis: principles and results of surgical management. Thorac Cardiovasc Surg. 2013;61(7):619-625. doi:10.1055/s-0033-1334996 Reference #2: Machado NO. Pancreaticopleural fistula: revisited. Diagn Ther Endosc. 2012;2012:815476. doi:10.1155/2012/815476 DISCLOSURES: No relevant relationships by Ibrahim Asghar Abid, source=Web Response No relevant relationships by Lakshmi Priyanka Mahali, source=Web Response No relevant relationships by Noa Tal, source=Web Response