Pancreaticopleural Fistula in a Patient with Chronic Pancreatitis

Abstract

Introduction: A case of massive pleural effusion without ascitis secondary to a pancreaticopleural fistula (PPF) successfully treated with pancreaticoduodenal stenting is presented. Case Description: A 34-year-old male presented to the emergency department with a 3-week history of dyspnea. Past medical history indicated alcohol-induced chronic pancreatitis. Physical examination was notable for diminished vesicular murmur and dullness on percussion of left lung. Chest X-ray revealed left-side massive pleural effusion, which was confirmed by pleural echography and contrast-enhanced CT of the chest. A black-colored pleural fluid was removed via chest drainage. The exudative pleural fluid had highly elevated amylase levels (>30 000 IU/L), in comparison to serum amylase (1082 IU/L). Both fluid culture and cytology were negative. Magnetic resonance cholangiopancreatography (MRCP) performed on day four revealed a new retroperitoneal pseudocyst (3.1 x 9 x 14.7 cm) communicating with the left pleural space through a 5-mm diaphragmatic fistula. No connection between the duct of Wirsung and the collection was identified. Initial treatment consisted of octreotide and gastrojejunal nutrition. Endoscopic retrograde cholangiopancreatography (ERCP) was then performed to locate a connection with the pseudocyst. It was during the second attempt on day 20 that a connection was found with contrast extravasion to the retroperitoneal cyst. A pancreatic duct stent (7 French diameter) was inserted to cover the site of duct disruption. On day 34, MRCP revealed near complete resolution of the pseudocyst. The patient was released with enteral nutrition and octreotide without any signs of left pleural effusion re-accumulation. Discussion: PPF are unusual and occur in 0.4-5% of patients with chronic pancreatitis. Very high amylase levels in pleural fluid support the diagnosis. MRCP is the non-invasive imaging tool of choice for visualizing anatomic relationships with peripancreatic collections. Conservative management with octreotide and parenteral nutrition for 2-3 weeks has traditionally been the first-line therapy recommended; nevertheless, a growing number of case reports suggest that successful closure of PPF with pancreatic duct stenting is feasible when duct anatomy is amenable to an endoscopic procedure. Observational data suggest that earlier invasive therapy could reduce hospital stay length when compared to the conservative strategy. Conclusion: This case highlights the prompt recognition of PPF by a medical team and the early use of endoscopic pancreatic stenting with somatostatin analogue as a primary therapeutic option associated with rapid amelioration of patient condition.