S1549 An Ominous Connection Causing Recurrent Pleural Effusions

Abstract

Introduction: Fistulation is a rare complication of chronic pancreatitis. Pancreaticopleural fistula (PPF) typically presents with thoracic symptoms. Pathogenesis is related to pancreatic duct obstruction causing leakage of pancreatic fluid, and if persistent can lead to fistula formation. Due to its predominant thoracic over abdominal symptoms, the diagnosis and treatment of PPF are usually delayed. The following case is an example of the potential need for repeat testing to confirm the diagnosis of PPF as well as a multidisciplinary approach to treatment. Case Description/Methods: A 66-year-old white woman presented to the emergency department with 10 days history of worsening dyspnea, orthopnea, and chest tightness. Her medical history was notable for alcohol-induced chronic pancreatitis. On physical examination, she was tachycardic with diminished breath sounds bilaterally. Chest CT angiogram revealed bilateral pleural effusions. Diagnostic right sided thoracentesis revealed exudative fluid pattern, but negative for infection and malignancy. Symptoms initially improved after therapeutic thoracentesis, but pleural effusions shortly recurred requiring repeat thoracenteses. Pleural effusions laboratory findings on thoracenteses are listed in Tables 1 and 2. MRCP showed an irregular tubular tract extending cephalad from the pancreas toward the right diaphragmatic crus and appeared to communicate with the right hydropneumothorax (Figure 1). ERCP was performed which showed diffuse dilatation of the pancreatic duct (Figure 2). Patient underwent therapeutic stenting to the ventral pancreatic duct (Figure 3). She had complete resolution of symptoms and pleural effusions on 2 months follow-up chest CT. Discussion: Pancreatic pleural fistula is a rare complication of chronic pancreatitis and can be a challenging diagnosis as symptoms tend to overlap with other causes of dyspnea, hypoxia and pleural effusions. MRCP is the most sensitive imaging modality, followed by ERCP and CT to visualize pancreatic duct anatomy and guide further therapeutic management. Conservative medical management with bowel rest and somatostatin analog are shown to be effective in patients without pancreatic ductal obstructions. In cases with recurrent pleural effusions despite conservative management, ERCP with therapeutic stenting to alleviate pancreatic ductal obstructions is strongly indicated with high success rate. Owing to its rarity and complexity, a multidisciplinary approach to PPF is warranted to provide the best care possible.Figure 1.: Tables and Figures.