B0040 - Trapped Lung From Pancreatico Pleural Fistula: A Rare Complication of Acute Pancreatitis

Nirupama Ancha, BBA¹, Sara Gottesman, MD¹, Edgar Torres Fernandez, MD¹, David Ben-Nun, MD¹, Tahir Mian, MD¹, Deepak Agrawal, MD, MPH, MBA^2
1Dell Medical School at the University of Texas at Austin, Austin, TX; ²Dell Medical School, Austin, TX

Introduction: Pancreaticopleural fistula (PPF) is a rare complication which occurs in approximately 0.4% of patients after pancreatitis [1]. Pancreatic fluid can fistulalize through the esophageal or aortic hiatus or directly through the diaphragm resulting in a unilateral or bilateral pleural effusion [1,4]. Management of PPF is based on clinical manifestations.

Case Description/Methods: A 46-year-old woman presented to the emergency department three weeks after hospitalization for gallstone pancreatitis with severe abdominal pain and shortness of breath. Physical exam was pertinent for tachycardia, diminished breath sounds over the left lung, and epigastric tenderness. Labs revealed normal lipase of 55 and elevated serum amylase to 238. Computed tomography (CT) scan of the chest, abdomen, and pelvis showed multiple pancreatic and peripancreatic fluid collections with the largest walled off necrosis in the pancreatic body measuring 12x6 cm and a large, loculated, left pleural effusion with collapsed left lung. Direct endoscopic necrosectomy with lumen-apposing metal stents (LAMS) was performed. Thoracentesis showed amylase >2960 units/L in the pleural fluid suggesting the presence of a PPF. Four days following placement of a 24 French chest tube, the effusion persisted and the lung remained collapsed. The administration of intrapleural tissue Plasminogen Activator (tPA) (10mg) and dornase (5mg) through a 10 French pigtail drain for three days resulted in lung expansion one day after the last dose. Chest tubes were removed. Necrosectomy was repeated a week later and LAMS were removed. There was no recurrence of pleural effusion or pancreatitis after 6 month follow-up.

Discussion: PPF is a rare complication of pancreatitis diagnosed by high amylase in the pleural fluid [2]. PPF has traditionally been treated by transpapillary drainage of the pancreatic duct with pancreatic duct stents [3] and therapeutic thoracentesis. In this case, thoracentesis with chest tube drainage was not successful in lung reexpansion, presumably due to trapped lung from pleural fibrosis. The next step is usually surgical decortication, but we then took a novel approach of co-administering ribonuclease and protease into the pleural space. Cystgastrostomy had already been performed to prevent any reaccumulation of fluid. This approach allowed resolution of the PPF while avoiding operative procedures.


Disclosures:


Nirupama Ancha, BBA¹, Sara Gottesman, MD¹, Edgar Torres Fernandez, MD¹, David Ben-Nun, MD¹, Tahir Mian, MD¹, Deepak Agrawal, MD, MPH, MBA². B0040 - Trapped Lung From Pancreatico Pleural Fistula: A Rare Complication of Acute Pancreatitis, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.