Spontaneous Internal Pancreatic Fistula Presenting with Persistent Pleural Effusion

Abstract

A 50 year old male patient presented with unexplained shortness of breath for one month. He had no known co- morbidities. His social history was significant for excessive alcohol consumption. Physical exam revealed decreased breath sounds on the right side with dullness to percussion. No abdominal tenderness was noted. Chest radiograph revealed a large right sided pleural effusion, which reformed shortly after pleurocentesis. Magnetic resonance pancreatography (MRP) showed changes of chronic pancreatitis with outpouching from the main pancreatic duct, raising the suspicion a pancreaticopleural fistula. Pleural fluid amylase level was elevated at 43920 U/L. Endoscopic retrograde cholangiopancreatography (ERCP) revealed irregular pancreatic duct with significant contrast leak from the tail, communicating with the right hemi-thorax (Fig 1). Due to significant disruption of pancreatic duct, the decision was made to proceed with distal pancreatectomy. Surgical pathology revealed a 2 cm size fistula originating from the distal pancreatic duct. The patient had an uneventful recovery from surgery.Figure 1Discussion: Internal pancreatic fistulas are uncommon complications of chronic pancreatitis. In most cases, the diagnosis can be made from CT scan, ERCP and MRP, where disruption of the main pancreatic duct is noted. Medical therapy options, including total parenteral nutrition, chest tube placement, octereotide, and nasopancreatic drain, have resulted in resolution of the fistula in 1/3 of the cases described previously. Pancreatic duct stenting has proven to be successful in some cases if done early in the course of the disease. Approximately 50% of the cases described in literature had to undergo surgery, with distal pancreatectomy being the most common resection performed. This choice of treatment is usually considered once medical treatment fails, or in cases where medical therapy is considered less effective, as in the cases of complete ductal disruption. Our patient had significant distal pancreatic duct disruption on top of extensive chronic pancreatitis, making the surgical option more practical. [figure 1]