SESSION TITLE: Critical Care 1 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Pancreaticopleural fistula (PPF) is a rare complication of acute pancreatitis. It is difficult to diagnose and should be suspected in the appropriate setting. Treatment modalities are debated in medical literature. We present an acute catastrophic presentation of PPF with full recovery after conservative management. CASE PRESENTATION: 74 yo female presented to the ER with epigastric pain. Serum Lipase was 8042. CT abdomen suggested acute pancreatitis without common duct stone and was negative for pleural effusions. Patient was kept NPO and started on IV fluids and pain control. Next day, she developed acute chest pain and respiratory failure requiring mechanical ventilation. Chest X-Ray showed new moderate right pleural effusion. Thoracentesis drained 1000 mL of greenish exudative pleural fluid with Bilirubin 2.1 mg/dL, Amylase 6913 U/L and Lipase 8282 U/L which suggested an acute presentation of PPF. She suffered multi-organ failure requiring 4 vasopressors and Hemodialysis. Chest tube was inserted. Antibiotics and Octreotide 50 mcg IV Q8 hours were started. She gradually improved with conservative measures. She was extubated and chest tube removed after 11 days, then discharged after 21 days. DISCUSSION: PPF usual presentation is a pleural fluid analysis with elevated amylase or lipase. CT has sensitivity of 33-47% at identifying PPF. ERCP has better sensitivity at 46-78% with the advantage of being a diagnostic and therapeutic procedure. MRCP has highest sensitivity of 80%. Medical versus invasive treatment with ERCP or surgery is debated in current literature. Candidates for medical management with octreotide and thoracentesis or tube thoracostomy if needed are patients with normal or mildly dilated pancreatic duct. Octreotide is used to reduce the pancreatic exocrine function and promote fistula closure. Success rate of medical treatment is 31-65 %. Failed medical management is associated with increased morbidity. Placement of a stent using ERCP shunts pancreatic secretions and promotes healing. Patients with complete ductal obstruction may benefit from early surgical intervention. King et al success rate with early surgical intervention was 94%. Distal pancreatectomy followed by pancreaticojejunostomy were the most common surgeries reported. In our case, early intervention with tube thoracostomy, antibiotic treatment and octreotide had great impact on overall clinical improvement. CONCLUSIONS: PPF is a rare complication of acute pancreatitis that can manifest with pleural effusion and respiratory failure. Supportive care with drainage, antibiotics and octreotide can avoid the morbidities and mortalities associated with surgical interventions in selected cases. Reference #1: Ali T, et al. Pancreaticopleural Fistula. Pancreas. 2009;38(1):e26-e31 Reference #2: Aswani H, et al. Pancreaticopleural Fistula: A Review. Journal of Pancreas. 2015;16(1):90-94 Reference #3: King J, et al. Pancretic-pleural fistula is best managed by early operative intervention. Surgery. 2009;147(1):154-159 DISCLOSURE: The following authors have nothing to disclose: Margaret Tajak, Thomas Evely, Mahmoud Amarna, Camelia Chirculescu, Haytham Adada No Product/Research Disclosure Information