Upstate Medical University Syracuse, NY, United States
Michael Sandhu, MD, Michelle Bernshteyn, MD, Sanchari Banerjee, MD, Michael Kuhn, MD Upstate Medical University, Syracuse, NY
Introduction: Chronic pancreatitis presents with epigastric abdominal pain, nausea, vomiting, and weight loss. Acute pancreatitis can also present with a pleural effusion which is typically left-sided, mild in nature, and self-limiting. However, recurrent bouts of pancreatitis may lead to a pancreaticopleural fistula (PPF) with a large, rapidly recurring, unilateral pleural effusion. Among patients with PPF, the most common presenting complaint is dyspnea. We present the diagnosis of a rare complication of chronic pancreatitis and discuss the management and options for treatment.
Case Description/Methods: A 53-year-old man with recurrent bouts of pancreatitis in the setting of alcohol presented with progressively worsening shortness of breath. A Computed Topography (CT) scan of the thorax demonstrated a large right-sided pleural effusion with a small portion of aerated right upper lobe. A thoracentesis was performed with 2,000 mL of cloudy orange fluid removed and sent for analysis. Despite fluid removal, the patient continued to complain of shortness of breath. Repeat imaging demonstrated recurrence of the effusion. The patient’s pleural fluid studies showed an exudative effusion with amylase significantly elevated at 18,382 U/L. An endoscopic retrograde cholangiopancreatography (ERCP) was performed, showing a pancreatic duct leak in the tail of the pancreas (Figure 1). A pancreatic sphincterotomy was performed and a stent was placed into the ventral pancreatic duct. The patient’s shortness of breath improved and he was discharged home with outpatient follow-up.
Discussion: Chronic pancreatitis results from episodes of acute pancreatitis and is a pathologic response to recurrent pancreatic injury. With recurrent bouts of pancreatitis, pancreatic enzymes can dissect into the pleural cavity, creating a tract. This communication may be anterior, leading to a PPF, or posterior with fluid draining into the retroperitoneum. PPF management ranges from conservative medical therapy to surgical interventions and is controversial without definitive criteria to guide therapy. Medical therapy involves parenteral nutrition and infusion of somatostatin analogs, with or without pleural drainage. ERCP has emerged as both a diagnostic and therapeutic modality for PPF as duct disruption is often amenable to stent placement. ERCP with stent placement is used to keep the pancreatic duct open and allow pancreatic secretions to flow into the duodenum instead of the pleura.
Figure: Figure 1: Endoscopic retrograde cholangiopancreatography imaging showing stent placement after identifying duct leak in the tail of the pancreas
Michael Sandhu indicated no relevant financial relationships.
Michelle Bernshteyn indicated no relevant financial relationships.
Sanchari Banerjee indicated no relevant financial relationships.
Michael Kuhn indicated no relevant financial relationships.
Michael Sandhu, MD, Michelle Bernshteyn, MD, Sanchari Banerjee, MD, Michael Kuhn, MD. P1097 - Rapidly Accumulating Pleural Effusion: A Sequela of Chronic Pancreatitis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.