Pancreatico-Pleural Fistula Presenting as Recurrent Bilateral Pleural Effusion: A Rare Complication of Chronic Pancreatitis

Abstract

Pancreatico-Pleural Fistula (PPF) is a rare complication of chronic pancreatitis associated with significant morbidity and mortality. Diagnosis requires a high level of suspicion and management can be very challenging. We present an unusual presentation of recurrent bilateral pleural effusion secondary to PPF. 62 year old female presented to the hospital with worsening shortness of breath. History of multiple admissions in the last 6 months for recurrent left sided pleural effusions. Thoracentesis done at each visit revealed exudative nature of fluid but failed to identify the underlying etiology. Past history significant for an episode of pancreatitis in 2014 secondary to gall stones for which she underwent cholecystectomy. Chest X-ray revealed bilateral pleural effusions and patient eventually underwent bilateral chest tube placement. CT scan of the chest and abdomen revealed massive bilateral pleural effusion along with calcification of the pancreatic head and dilated pancreatic duct. Also noted were a 4 cm pseudocyst in the body and 7 cm pseudocyst in the tail of the pancreas with connection to the pleural space (Image 1,2). Pleural fluid amylase was elevated at 6915 U/L & lipase >3000 U/L. Patient subsequently underwent ERCP and a pancreatogram revealed a high grade stricture in the neck of the pancreas with extravasation of dye at the tail consistent with an internal pancreatic fistula. A 10 cm 7 fr plastic stent was successfully placed and patient was started on octreotide. Patient was subsequently discharged with bilateral pleurex catheters and daily octreotide injections. Day 60 follow up noted the pleural fluids secretions to be minimal with continued use of octreotide. Pancreatico-Pleural Fistula presenting as recurrent bilateral pleural effusions is an extremely rare complication of chronic pancreatitis. Pleural effusion due to PPF accounts for less than 1% of cases, while pleural effusion can be seen in 3—7% of patients with pancreatitis .Diagnosis requires a high degree of suspicion with supporting laboratory and radiological studies. Conservative treatment with pancreatic duct stenting and/or octreotide has been successful in 31—45% of cases, while surgery is curative in 80—90% of cases but with a high rate of mortality upto 10%. Combination of medical management and interventional endoscopy successfully reduced the pleural drainage in our patient.1400_A.tif Figure 1: CT scan of the chest and abdomen showing massive bilateral pleural effusion along with calcification of the pancreatic head with dilated pancreatic duct.1400_B.tif Figure 2: CT scan chest and abdomen showing a 4 cm pseudocyst in the body and 7 cm pseudocyst in the tail of the pancreas with connection to the pleural space