S1814 Plasmapheresis in the Treatment of Severe Hypertriglyceridemia-Induced Pancreatitis: A Case Report

Abstract

Introduction: Acute pancreatitis is a common diagnosis with established guidelines of treatment and patient monitoring. Further known are the potential for common sequelae such as transition to chronic pancreatitis, calcification, and nutritional deficiencies. Lesser known and published in literature are the pleural sequelae of pancreatitis, namely the potential for pancreaticopleural fistulization. Here, we present a case of pancreatitis with pleural fistula formation to shed light on the common presentation, evaluation and treatment methods of this less common diagnosis. Case Description/Methods: The patient is a 47-year-old male with a history of alcoholism with prior episodes of pancreatitis, presenting with a complaint of dyspnea. The patient had abdominal pain, as well as elevation of lipase concerning for pancreatitis. Initial imaging demonstrated bilateral pleural effusions for which the patient underwent right sided thoracentesis with fluid studies demonstrating elevated lipase, amylase, and protein. Initially, conversative management was pursued for pancreatitis with NPO status and fluid resuscitation. Without noted clinical improvement, MRCP was performed which demonstrated a concern for fistulization from the pancreatic duct to the lesser sac of the stomach and potential pancreatic pleural fistula formation. With gastroenterology consultation, the patient underwent ERCP with placement of a pancreatic duct stent. With continued clinical decline, CT surgery consultation was requested for recurrence of the pleural effusions. The patient underwent right sided decortication with chest tube placement and bronchoscopy further confirming the diagnosis of pancreatic pleural fistulization. Discussion: With this case, we establish the pattern used for treatment of fistulization. Literature purports initial management to be conservative with NG or parenteral nutrition. Due to our patient's clinical decline, second line treatment was initiated with endoscopic evaluation. As the patient continued to have pleural effusion formation bilaterally, which while only seen in 15% of cases, prompted tertiary treatment modalities with surgical decortication. This pattern also suggests that should treatment continue to fail, next steps would justify pancreatic drainage or pancreatic resection (Bak et al). Our case provides insight into the step-wise approach to pancreaticopleural fistula management with unique imaging findings, adding to medical literature the management of a lesser known complication of pancreatitis.