Title: Pancreatic pleural effusion: A rare complication of chronic pancreatitis

Author(s): Ayesha Khadka, MD; Mohammad M. Qazziha, MD; Molly Howsare, DO; Jon Arnott, MD; Emma Nowakowski, BS

Email: akhadka@mercy.com

Introduction: Pancreatopleural effusion is one of the most uncommon complications of recurrent acute on chronic pancreatitis with sources citing its prevalence to 0.4%¹. Massive rapidly forming Pancreatopleural effusions formed secondary to pancreatopleural fistulas compress the thoracic cavity leading to presentations with respiratory symptoms such as dyspnea, chest pain and cough. We present a case of a young alcoholic patient who presents with symptomatic massive left sided pleural effusion that correlates with his CT abdomen/pelvis findings.

Case summary: A 51-year-old male presented to urgent care with a 2-week history of progressive dyspnea and a productive cough. Past medical history was significant for alcohol and tobacco use, chronic pancreatitis with multiple admissions for acute pancreatitis, and prior cholecystectomy. Chest radiograph and subsequent CT of the chest revealed a large left pleural effusion.  Lab work revealed leukocytosis, thrombocytosis and hypokalemia.  A left sided pig-tail catheter was placed and drained 1.6L of amber fluid with significant residual pleural effusion post procedure. The fluid was exudative in nature, Amylase was >7500 u/L. Cardiothoracic surgery was consulted due to concern for a pancreatic fistula. The patient underwent a VATS and decortication which revealed a fibrothorax and developing empyema. The patient was empirically treated with antibiotics and cultures remained negative. Initial follow up CXR after discharge showed complete resolution of the effusion. He returned to the hospital due to similar symptoms approximately two months later and a pancreatic stent was placed.

 

Discussion: The pathophysiology behind the formation of pancreatopleural effusions is either a transdiaphragmatic lymphatic blockage leading to effusion, or pancreatic duct disruption subsequently forming a pseudocyst leading to formation of a pancreatopleural fistula (PPF) and a massive effusion. Studies show that around 65% -75%³ of patients present with dyspnea with imaging showing large unilateral effusions. Although there are no diagnostic threshold levels for amylase levels, Pleural fluid amylase has been established as an initial screening test. A threshold greater than >1000 with a mean value above 10,000 has been cited in many studies

 

Management of PPF can either be medical, surgical or endoscopic in nature. Medical management targets reducing exocrine secretions with somatostatin analogues and parental nutrition. With the emergence of ERCP, ERCP with stent placement is now used as both a diagnostic and therapeutic modality. In our patient, transthoracic drainage of the pleural fluid provided a temporary resolution of the effusion and of symptoms. ERCP with a pancreatic stent was subsequently placed for definitive management of the pancreatopleural fistula.