Diagnosis and management of pancreaticopleural fistula

Abstract

Pancreaticopleural fistula is a rare diagnosis requiring a high index of clinical suspicion due to the predominant manifestation of thoracic symptoms. The current literature suggests that confirmation of elevated pleural fluid amylase is the most important diagnostic test. Magnetic resonance cholangiopancreatography is the recommended imaging modality to visualise the fistula, as it is superior to both computed tomography and endoscopic retrograde cholangiopancreatography (ERCP) in delineating the tract within the pancreatic region. It is also less invasive than ERCP. While a trial of medical regimen has traditionally been the first-line treatment, failure would result in higher rates of complications. Hence, it is suggested that management strategies be planned based on pancreatic ductal imaging, with patients having poor chances of spontaneous closure undergoing either endoscopic or surgical intervention. We also briefly describe a case of pancreaticopleural fistula in a patient who was treated using a modified Puestow procedure after failed endoscopic treatment.

A Case of Pancreaticopleural Fistula Successfully Treated with a Pancreatic Duct Stent

“…Pancreaticopleural fistula is a rare condition particularly affecting middle-aged men with alcohol-induced chronic pancreatitis with pancreatic pseudocyst [1][2][3]. More than 60% of patient will be dyspneic at the clinical presentation [1].…”

“…There is often a delay between clinical presentation and diagnosis because of the severity of respiratory complaint presented by patient. Therefore, clinician must be suspicious for PPF with patient known for chronic pancreatitis disease and presenting with a new pleural effusion [2,3]. The most important diagnostic test for PPF is an exudative pleural effusion with a high amylase count.…”

“…No threshold of amylase level is described in the literature to confirm a diagnosis of PPF but levels above 50 000 IU/L are only described in that condition. Clinicians should remember that others conditions can present with a high amylase count in a pleural tap: acute pancreatitis, pneumonia, cancer, oesophagus perforation and pulmonary tuberculosis [1][2][3]. The sensitivity of CT scans to detect pancreaticopleural fistula is low in comparison to MRCP and ERCP that have sensitivities around 80% [1].…”

“…MRCP is a non-invasive tool that provides image of whole pancreas and possible pseudocyst. Compare to ERCP, MRCP allow physician to see the Wirsung duct above a stricture site or lithiasis [2,4]. ERCP is a user-dependent technique with possible complications like pancreatitis, infection and haemorrhage risks [2,5].…”

“…Pancreaticopleural fistula (PPF) is a rare complication of pancreatitis, occurring in 0.4% of patients with pancreatitis and in 4.5% of patients with pancreatic pseudocyst [1,2]. Most of the PPF form by leak of pancreatic secretion from a pancreatic pseudocyst.…”