We Sprung a Leak! Pancreaticopleural Fistula: An Uncommon Case of Pancreatic Leak in Chronic Pancreatitis

Abstract

Internal pancreatic fistula (IPF) is a rare cause of pancreatitis-related pleural effusion. Identification of IPF is essential for appropriate management. We present a case of a pleural effusion secondary to a pancreaticopleural fistula (PPF). Routine imaging did not identify a fistula initially, but transpapillary stent for presumed fistula resulted in resolution of symptoms. A high level of suspicion for PPF is essential when presented with pancreatitis-associated pleural effusion, and treatment should be guided by the overall clinical scenario. A 43- year-old male with alcoholic cirrhosis, chronic pancreatitis, and pancreatic pseudocyst presented to the emergency department with dyspnea. On exam, he had diminished breath sounds at the left mid lung base and epigastric tenderness. Serum lipase was 724 U/L. CT chest with contrast revealed a large simple pleural effusion with near-complete collapse of the left lung, and a pseudocyst at the head of the pancreas. Magnetic resonance cholangiopancreatography (MRCP) revealed a pancreatic pseudocyst with the superior margin extending beneath the right diaphragmatic crus. A thoracentesis extracted one liter of fluid, with amylase greater than 30,000 U/L. He underwent three additional thoracenteses due to rapid re-accumulation of effusion. An endoscopic retrograde cholangiopancreatography (ERCP) was performed with placement of a pancreatic duct stent for suspected fistula. After placement, the recurrent pleural effusion resolved. The pancreaticopleural fisutula was not identified on initial imaging nor initial ERCP, a repeat ERCP visualized a fistula, confirming the diagnosis. Pleural effusion due to pancreaticopleural fistula is rare, occurring in 0.4-4.5% of pancreatitis patients. The diagnosis of PPF includes elevated pleural fluid amylase and imaging to confirm disruption of the pancreatic duct. In this case, elevated pleural amylase and high level of suspicion led to accurate treatment despite absent visualization of PPF on initial imaging and ERCP. Conservative management is first indicated for a pancreaticopleural fistula, including thoracentesis, parenteral nutrition, and octreotide. If conservative therapy fails, ERCP with transpapillary stenting is recommended. Differential includes disconnected duct syndrome, which may not respond to endoscopic measures, and often requires surgery. The ability to recognize a pancreaticopleural fistula is essential for proper management of these patients.Figure 1Figure 2