Pancreaticopleural Fistula

Abstract

Purpose: Pancreaticopleural fistula (PPF) is a rare entity in which pancreatic secretions drain directly into the pleural cavity. A case is described herein of PPF in a patient with chronic pancreatitis. A 43-year-old male presented with a 4-week history of dysnea, chest pain, cough and a history of alcoholism. On examination he had features of pleural effusion that was confirmed by chest X-ray showing a large left sided pleural effusion. Lab analysis revealed a serum amylase of 651 IU/L (reference range: 0–150 IU/L). A CT scan showed a large left pleural effusion and atrophic pancreas with pseudocysts. Pleural aspiration was done six times without resolution of the effusion. Pleural fluid analysis showed an amylase of 11,990 IU/L. The patient was diagnosed with a PPF and started on octreotide. An ERCP showed an irregular pancreatic duct and a leak from the distal pancreatic duct into the left pleural cavity; a 12 cm 7 Fr pancreatic stent was inserted across the area of disruption. He was discharged on octreotide and a repeat chest X-ray showed no pleural effusion. The patient's pancreatic stent was removed and he is doing well. PPF is a rare complication of chronic pancreatitis. Pleural effusions from pancreatitis are due to irritation of the diaphragm. In contrast, PPF is thought to result from direct pancreatic duct fistulazition, or by pseudocyst passage through diaphragmatic defects. Pleural effusions tend to be recurrent, and analysis of the pleural aspirate reveals a much higher amylase in the setting of PPF as compared to pleural effusions due to pancreatitis. Although an algorithm for evaluation of suspected pancreaticopleural fistula remains to be established, computed tomography has traditionally been the initial imaging modality of choice despite only identifying fistulas less than half the time. ERCP, although invasive, is more sensitive in demonstrating fistulas than CT (79% vs. 43%) and allows for therapeutic intervention at that time3. MRCP may be a promising imaging modality for the future, but remains to be evaluated. A recent review showed that 100% of patients treated with pancreatic stents had complete resolution compared with 0–33% of those who were managed alone with a chest tube, TPN, and octreotide. The authors recommended early endoscopic intervention. Chest tube placement is reserved for those with respiratory compromise. Surgery should only be contemplated as a last resort.