Two Patients with Chronic Pancreatitis Complicated by a Pancreaticopleural Fistula

Abstract

Two patients presented with dyspnea and signs of chronic pancreatitis. Patient B had pleural effusion on chest X-ray. Patient A developed pleural effusion during the course of disease. On further analysis these pleural effusions showed elevated amylase concentrations. This finding suggested the diagnosis of a pancreaticopleural fistula which was confirmed by magnetic resonance cholangiopancreatography. Because of the distinct localization of the fistulas the patients were treated differently. In patient A an endoprosthesis was successfully placed in the pancreatic duct, and patient B underwent distal pancreatic resection. Considering the rarity of pancreaticopleural fistula, there is no consensus on diverse aspects of treatment, such as length of treatment with octreotide. However, a rationale for the distinction between fistulas suited for treatment with endoprosthesis or surgery seems to provide some grip.

Diagnosis and management of pancreaticopleural fistula

“…(8,17) As such, despite its lack of therapeutic options, MRCP is considered the imaging study of choice for PPF due to its superiority over CT in identifying a fistula in the pancreatic region and its noninvasiveness as compared to ERCP. (17) Visualising the site of fistulisation and its exact anatomical relationship to the pancreatic ductal tree is particularly useful in the planning of surgical intervention, if surgery is being considered. and chest drainage for 6-24 days.…”

Pancreaticopleural fistula: an overlooked entity

“…Abdominal symptoms are seen in 24% of cases. 5,6 Pancreatic symptoms in PPF are almost never recorded. 1 This creates a delay in diagnosis which requires a high index of suspicion.…”

“…7,8 The pathogenesis of PPF involves a pancreatic duct stenosis or leak, which can result from trauma, surgery, ERCP, or pancreatitis. 1,5 It is very difficult to demonstrate the fistula radiologically. ERCP is mandatory in such cases to document duct pathology and aid decision making.…”

“…Limitations of stenting are a distally located fistula and completely ruptured or obstructed duct. 1,5 Complications of medical management include malnutrition, central catheter infection, deep vein thrombosis, and sepsis. Surgical management is indicated in failure of medical management (3-4 weeks are considered) or obstructed pancreatic duct.…”

A surprising diagnosis of pancreatitis with pseudocyst associated with sudden massive effusion

“…Recurrent pleural effusions may develop. Although effusions are generally on the left, they may also be observed on the right or bilateral side (3,(5)(6)(7)(8). In chronic pancreatitis, the cause of pleural effusion is attibuted to the direct extension of a pseudocyst across the diaphragm.…”