PANCREATIC-PLEURAL FISTULA PRESENTING AS RECURRENT UNILATERAL PLEURAL EFFUSION

Abstract

SESSION TITLE: Critical Care 3 SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Pancreatic-pleural fistula (PPF) is a rare complication of pancreatitis. Pleural effusion seen with pancreatitis is usually clinically insignificant but PPF can produce recurrent and large volume pleural effusions. CASE PRESENTATION: A 58-year-old male with a medical history significant for alcohol abuse and recurrent alcoholic pancreatitis presented to our institute with worsening shortness of breath for 2 days.He was recently admitted for the third time to the hospital with similar presentation and was diagnosed with massive left-sided pleural effusion requiring drainage for symptom relief. He started feeling short of breath the very next day after discharge, more on exertion. On admission, his vitals were: HR 118, BP 140/97, RR 22, Temp 98.2F. Physical examination was remarkable for dullness to percussion with reduced air entry up to the left 5th intercostal space.Laboratory workup revealed a serum lipase level of > 600 U/L, serum amylase of 459 U/L mm/hr.Chest x-ray showed opacification of left hemithorax. CT chest confirmed large left-sided pleural effusion with compression collapse of the left lower lung.Pleural fluid analysis showed an exudative effusion with an amylase level of 17675 U/L. MRCP of the abdomen revealed diffusely dilated pancreatic ducts.Despite repeated aspiration, recurrent accumulation of pleural effusion was seen, so a chest tube was inserted.An ERCP was performed for the concern of pancreatic-pleural fistula which was consistent with moderate ductal stenosis and contrast extravasation from the ventral pancreatic duct in the head of the pancreas but did not demonstrate a clearcut fistulous tract. A stent was placed in the stenotic duct. The pleural fluid drainage from the tube decreased markedly, the chest tube was removed next day and a follow-up chest X-ray after 2 weeks revealed no evidence of recurrent pleural effusion. DISCUSSION: Although uncommon, pancreatic-pleural fistula can present with recurrent unilateral clinically significant pleural effusion. Although there is no cutoff level to establish the diagnosis, pleural fluid amylase is usually greater than 1000U/L, with levels of> 50,000U/L highly suggestive of a PPF.ERCP is essential in both the diagnosis and treatment of PPF; it does not only show the site of the leak but also reveals the ductal morphology, it demonstrates the fistulous tract in 59% to 74% of the cases. In our patient, the diagnosis was initially suggested by the very high level of pleuritic fluid amylase level and was confirmed by imaging and ERCP. Treatment was successful after a stent was placed at the site of leakage. CONCLUSIONS: Pancreatic-pleural fistula (PPF) should be included in the differential diagnosis of recurrent and large pleural effusions especially in middle-aged men with a history of alcohol consumption and recurrent pancreatitis. Reference #1: A. R. Dhebri and N. Ferran, “Nonsurgical management of pancreaticopleural fistula,” Journal of the Pancreas, vol. 6, no. 2, pp. 152–161, 2005. Reference #2: R. Materne, P. Vranckx, C. Pauls, E. E. Coche, P. Deprez, and B. E. Van Beers, “Pancreaticopleural fistula: diagnosis with magnetic resonance pancreatography,” Chest, vol. 117, no. 3, pp. 912–914, 2000. Reference #3: E. W. Pottmeyer, C. F. Frey, and S. Matsuno, “Pancreaticopleural fistulas,” Archives of Surgery, vol. 122, no. 6, pp. 648–654, 1987. DISCLOSURES: No relevant relationships by Taha Ahmed, source=Web Response No relevant relationships by TALHA AHMED, source=Web Response No relevant relationships by Basma Ricaurte, source=Web Response