Thoracic Complications of Pancreatitis

Abstract

Pancreatitis may be associated with thoracic complications, notably chronic massive pleural effusion (CMPE) and, rarely, pseudocysts with mediastinal extension (PME) and enzymatic mediastinitis (EM). Our personal experience with 14 cases of thoracic complications (nine CMPE, two PME associated with pleural effusion, and three EM of 670 patients who underwent surgery; of these, 191 had acute and 479 had chronic pancreatitis) during 16 years (1970-1986) is reported. In the patients with CMPE, the initial symptoms were progressive dyspnea eventually associated with cough and chest pain. In the PME cases, there was dysphagia associated with left subscapular pain and left chest pain. The initial signs in the patients with EM were sudden dyspnea, cyanosis, retrosternal pain, tachycardia, and acute heart failure. A fistula between the pancreatic ductal system and the pleural cavity in seven of the nine patients with CMPE was demonstrated by intraoperative pancreatography and/ or cystography. On the contrary, preoperative endoscopic pancreatography demonstrated the sinus tract in only three of the seven. In both cases of PME, computed tomography (CT) provided a correct diagnosis that was confirmed at surgery. In the patients with EM, the diagnosis was suggested by the clinical appearance and was confirmed by the chest roentgenogram and by CT. All patients had operations after varying periods of unsuccessful 2-4-week-long conservative treatment. One patient with infected ascites died postoperatively. There were no thoracic recurrences of pancreatic disease among the other patients at a 10-month-10-year follow-up observation after surgery.

Rare case of internal pancreatic fistula in a young adult presenting with massive bilateral pleural effusion

“…It is a non-invasive alternative to ERCP and is useful when ERCP fails to give adequate information. ERCP and MRCP will identify the actual fistulous tract in 70% of cases 1. The most definitive investigation in our view is ERCP as it has both a diagnostic as well as a therapeutic role in the management of pancreatic pleural fistula.…”

“…Pancreatic amylase concentration in the pleural fluid in these cases is either normal or mildly elevated and the effusion resolves along with the pancreatitis. Internal pancreatic fistula results from posterior disruption of the pancreatic duct into the retroperitoneal space, leading to the formation of a fistulous tract between the pancreas and the mediastinum through the aortic or oesophageal hiatus1 where it forms a pseudo cyst. A pseudo cyst in the posterior mediastinum can rupture in one or both pleural cavities, giving rise to a large pleural effusion.…”

Pancreaticopericardial fistula: a rare complication of chronic pancreatitis

“…Location of the duct disruption could be the most important predictor of who would benefit from stenting for PD leak. Successful endotherapy depends on passing the guidewire across the leak and deploying a stent of appropriate length 11. If the leak persists after 2–4 weeks of conservative and endoscopic therapy, surgery may be required depending on the site of the leak.…”

Non-Cardiac Chest Pain of Non-Esophageal Origin

“…Chest pain may occur in some patients with pancreatitis, especially in cases of thoracic complications [ 39 ] . Chest pain from pancreatitis or complications of pancreatitis such as pseudocyst ( Fig.…”

“…Pneumonia and pleural effusions, most often located in the left hemithorax, are common conditions in acute pancreatitis that most of the times resolve with the improvement of the pancreatic disease. Other potential causes of chest pain in pancreatitis, most often associated to chronic pancreatitis of alcoholic origin, are mediastinal pancreatic pseudocysts and chronic massive pleural effusion secondary to pancreatic pleural fi stula [ 39 ] . These complications normally arise as consequence of a posterior disruption of the main pancreatic duct into the retroperitoneum and the leakage of pancreatic fl uid through the diaphragmatic aortic or esophageal hiatus into the posterior mediastinum [ 45,46 ] .…”