Pancreaticopleural Fistula Complicating Alcoholic Pancreatitis and Pancreas Divisum Successfully Treated with Minor Papillotomy and Stent Placement

Abstract

Introduction: Pancreaticopleural fistulas are an infrequent complication of pancreatitis, pancreatic trauma, or pancreatic surgery. Seventy to ninety percent of pancreaticopleural fistulas occur as sequelae to chronic pancreatitis. Several case reports have described the success of ERCP in the management of pancreaticopleural fistulas. However, we are aware of only two case reports of pancreaticopleural fistulas effectively managed with ERCP in the setting of pancreas divisum or pseudodivisum. We describe a case of pancreaticopleural fistula in the setting of alcohol pancreatitis and pancreas divisum successfully treated with ERCP and dorsal pancreatic duct stenting. Case Presentation: A 31-year-old female with a history of alcoholic pancreatitis presented with a recurrent left-sided pleural effusion and epigastric pain. On admission, her amylase was 819 U/L. Her chest X-ray was remarkable for a large left pleural effusion with lung collapse. The MRCP was notable for pancreas divisum and inflammation of the pancreatic head. Fluid was also seen tracking superiorly and communicating with the left pleural effusion. A left chest tube was placed and 2 liters of fluid was drained. Fluid analysis was notable for an amylase of 24608 IU/L and a lipase of 39595 U/L, confirming the diagnosis of pancreaticopleural fistula. ERCP demonstrated a normal biliary tree. On pancreaticogram, the ventral pancreatic duct was completely disrupted with contrast filling a fistulous tract. The minor papilla was then cannulated and pancreaticogram demonstrated a normal caliber dorsal pancreatic duct communicating with the same fistulous tract at the level of the genu of the pancreas. After minor papillotomy, a 5 Fr x 9 cm pancreatic stent with a single internal flap was placed through the minor papilla and into the dorsal duct bridging the disrupted area. After ERCP, the patient was started on parenteral nutrition and octreotide. The patient's chest X-ray remained clear 6 days after the stent was placed with minimal drainage from the chest tube. The chest tube was then removed and she was discharged home. Parenteral nutrition and octreotide were stopped 2 weeks later. Seven weeks after her ERCP, the pancreatic stent was removed. Pancreaticogram through the minor papilla demonstrated no extravasation of contrast and a healed fistulous tract. Discussion: Pancreaticopleural fistulas are rare with the majority of cases occurring in the setting of chronic pancreatitis. We describe the formation of a pancreaticopleural fistula in the setting alcoholic pancreatitis, pancreas divisum, and disrupted ventral and dorsal ducts. The pancreaticopleural fistula was successfully managed with trans-minor-papillary stenting of the dorsal pancreatic duct.