Charleston Area Medical Center Charleston, WV, United States
Lauren Searls, DO, Kristen P. Helmick, MD Charleston Area Medical Center, Charleston, WV
Introduction: Pancreaticopleural fistula (PPF) development is a rare complication of pancreatitis with majority of cases occurring in chronic pancreatitis secondary to alcohol use. Most common presenting symptoms are dyspnea, abdominal pain, and cough. PPF is diagnosed by elevated pleural fluid amylase and seen radiographically by CT, MRI, or ERCP.
Case Description/Methods: A 46 year-old M with history of chronic pancreatitis due to alcohol use presented to the ED with 2 days of epigastric pain radiating to the back, emesis, and decreased PO intake. He had EGD with EUS 2 months prior with a CBD stent placed. On presentation: HR 117, RR 24, SpO2 95% on RA, WBC 21.4, Lipase 582, LFT WNL. On exam, abdomen tender to palpation without rigidity or guarding and lungs clear to auscultation bilaterally. IV fluid resuscitation, pain control, and IV antibiotics were initiated. CXR showed small left pleural effusion (PE), CT Abdomen showed acute on chronic pancreatitis w/o necrosis, pancreatic tail fluid collection 5.9 x 3.7 cm, GE junction thickening with fluid collection extending to the pancreatic collection. Three days later, he developed abrupt shortness of breath, hypoxia (SPO2 80%) requiring non-rebreather, BiPAP, and subsequent intubation. A CXR showed enlarged LLL PE and a chest tube was placed. Pleural fluid was exudative with amylase 4,842 U/L (ref 11-82) growing Klebsiella Pneumoniae. MRI showed CBD dilatation with tapering at the pancreatic head, PD dilatation, and PPF on the left at the level of the GE junction. ERCP was performed with CBD stent removal. Residual stricture of the CBD was noted and dilated with balloon catheter. Contrast extravasation at the genu of the pancreas and complete PD disruption with severe stricture downstream involving the distal 2-3 cm of the PD were noted. The PD stricture was dilated with balloon catheter and a 4 French by 3cm PD stent with external flange was placed as well as two CBD stents. Repeat CTA showed small left PE and decreased pancreatic tail pseudocyst. He was discharged with plan for repeat ERCP in 4-6 weeks, likely requiring pancreatic surgery.
Discussion: Our case demonstrates a classic case of PPF with left sided pleural effusion and rapid development of severe respiratory distress. Empyema with growth of microorganisms is a less commonly found in PPF. Extent and location of PD disruption correlate with endoscopic success; however, endoscopic success remains highly variable.
Figure: Figure 1. a. CXR on admission. b. CXR with enlarging left pleural effusion.
Lauren Searls indicated no relevant financial relationships.
Kristen Helmick indicated no relevant financial relationships.
Lauren Searls, DO, Kristen P. Helmick, MD. P0069 - Pancreaticopleural Fistula: A Case of Severe Respiratory Distress, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.