Pancreaticopleural Fistula as a Complication of Chronic Pancreatitis

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Chronic pancreatitis and pleural effusions are common conditions encountered by clinicians. We present a case of pancreaticopleural fistula that reminds the clinician to consider a pancreatic source of a new pleural effusion in a patient with known chronic pancreatitis. A 64 year old male with a history of chronic alcoholic pancreatitis presented to the emergency department for shortness of breath and left sided chest pain of a few days duration. Chest x-ray showed a new left side pleural effusion. His dyspnea improved after removal of 2L of fluid, but his pleural effusion rapidly re-accumulated. Pleural fluid was exudative with lipase of 10539 U/L and amylase of 16674 U/L. Magnetic resonance cholangiopancreatography (MRCP) revealed a mid-pancreatic duct stricture and possible fistulous tract to the left pleural space. The patient was started on octreotide and placed on total parental nutrition (TPN). He subsequently underwent endoscopic retrograde cholangiopancreatography (ERCP) which confirmed a mid-pancreatic duct stricture with a fistula arising in the body of the pancreas. A pancreatic sphincterotomy was performed and a pancreatic duct stent was placed. He also underwent video assisted thoracoscopic surgery (VATS) with decortication of the organized left pleural effusion. In spite of this, patient developed a Vancomycin resistant enterococcus (VRE) empyema on the decorticated side, which was treated with chest tube drainage and antibiotics. He recovered completely over a course of 6 weeks. After serial pancreatic duct stenting for 6 months the pancreatic stent was removed and a pancreatogram showed persistent mid-pancreatic duct stricture without evidence of pancreatic duct leak. Pancreaticopleural fistula is a rare complication of chronic pancreatitis most commonly presenting with dyspnea and chest pain. Abdominal symptoms are often not present. Pleural fluid usually tends to be exudative and amylase or lipase analysis is necessary to make the diagnosis. Imaging such as MRCP or ERCP is required to identify a pancreatic duct disruption and or stricture. Treatment can include Octreotide, parental nutrition, and supportive care. ERCP with subsequent endotherapy for stricture is often required. Surgery is usually reserved for those cases not responsive to medical or endoscopic therapies. A multi-disciplinary approach is required in caring for these complicated patients.Figure 1Figure 2Figure 3