S3476 Workup of a Suspected Pancreaticopleural Fistula in a Young Male

Abstract

Introduction: Pancreatic fistulas are an abnormal connection between the pancreas and an adjacent or distant structure or organ. These can be characterized as internal or external depending if the pancreatic duct communicates with the skin or not. The most common cause of an internal pancreatic fistula is pancreatitis associated with chronic alcohol. Pancreatopleural fistulas develop by leakage of pancreatic exocrine secretions through the openings in the diaphragm. Here we present a case, where there was concern for a pancreatopleural fistula. Case Description/Methods: A 31-year-old male with past medical history of chronic recurrent pancreatitis complicated by enlarging pseudocysts and portal vein thrombosis was transferred to our facility from outside hospital for hemorrhagic pancreatic pseudoaneurysm status post IR embolization. He had been bleeding from the hemorrhagic pseudoaneurysm at the previous hospital and had been treated with an initial IR embolization procedure for this 4-5 days before arriving at our facility. He underwent repeat IR embolization procedure with repositioning of the malpositioned coil 6 days after admission and subsequently underwent EGD with endoscopic ultrasound and cysgastrectomy for treatment of his associated pancreatic pseudocyst 12 days after admission. Pleural effusion seen on Xray was thought to be secondary to pancreatic fluid accumulation. Thoracentesis was subsequently performed due to patient complaints of dyspnea and analysis showed > 12,000U/L of amylase and black fluid concerning for a pancreatic pleural fistula (Figure A). Patient had a repeat X-ray the following day with accumulation of the pleural effusion (Figure B). Patient was started on TPN and Octreotide for treatment. Repeat thoracentesis yielded amber colored fluid and a CT chest, abdomen and pelvis did not show evidence of fistula formation. It was determined that the initial thoracentesis performed on the patient was actually placed into the pancreatic pseudocyst due to severe elevation of the hemidiaphragm. The patient was ultimately discharged with plans to follow-up with general surgery as an outpatient for possible pancreatectomy. Discussion: We believe that our findings during the care of this patient are important for Gastroenterologists as they provide an excellent opportunity to review both the common and obscure complications of pancreatitis. entity that can occur in patients with acute pancreatitis and is characterized by small, left sided pleural effusions.Figure 1.: Figure A. Thoracentesis fluid obtained from patient concerning for a pancreatic pleural fistula. Figure B. Repeat chest x-ray showing re-accumulation of large left-sided pleural effusion.