Pancreaticopleural fistula complicating chronic pancreatitis

Abstract

SummaryPancreaticopleural fistula is an extremely rare complication of chronic pancreatitis with characteristic feature that it may appear in the absence of changes of acute pancreatitis. We present a case of a 32-year-old man whose CT scan showed multiple pseudocysts along the body and tail of the pancreas, left crus of diaphragm and in the posterior mediastinum with associated splenoportal thrombosis. MR cholangiopancreatography imaging diagnosed the case as a pancreatico-pleural fistula, with the fistulous tract connecting distal body and tail of the pancreas to the posterior mediastinum through a diaphragmatic hiatus with right-sided mild-to-moderate pleural effusion. Meanwhile the patient was treated conservatively for his acute symptoms that included pleural tap also. Finally, endoscopic retrograde cholangiopancreatography was done and minor papilla papillotomy was performed and a stent was placed. Knowledge about such cases would help one to be aware of such a rare but dangerous complication, so that timely and correct diagnosis and management can be undertaken. BACKGROUND

Primary presentation of chronic calcific pancreatitis with massive unilateral pleural effusion

“…Formation of pancreaticopleural fistulae has been suggested as the primary mechanism of development of pleural effusion in patients with chronic pancreatitis 2. Although such fistulae were directly demonstrated by MR and/or endoscopic retrograde cholangiopancreaticography in several case reports,1–3 they could not be demonstrated in our patient.…”

“…All these cases except one, however, were marked by obvious clinical clues to a possibility of chronic pancreatitis including a history of alcoholism, chronic abdominal pain or previous attacks of acute pancreatitis 2. In one instance, the patient had a prior diagnosis of chronic pancreatitis and subsequently developed pleural effusion 3.…”

Pancreaticopleural Fistula: A Rare Presentation and a Rare Complication

“…Pancreatic pseudocyst is defined as an abnormal collection of pancreatic secretions contained within a non-epithelial wall, that is composed primarily of granular and fibrous tissue [4]. Alcoholrelated chronic pancreatitis is the leading cause of fistula formation [1][2][3][4][5][6][7]. However, PPF can occur as a result of gallstone pancreatitis, idiopathic pancreatitis, trauma, or congenital anomalies of the pancreatic duct.…”

“…However, PPF can occur as a result of gallstone pancreatitis, idiopathic pancreatitis, trauma, or congenital anomalies of the pancreatic duct. PPF can be formed due to posterior pancreatic pseudocyst rupture into the retroperitoneum, causing the pancreatic secretions to ascend to the pleural space through the esophageal or aortic hiatus, or, due to the abnormal direct transdiaphragmatic connection of the pancreatic duct to the pleural space [1,3,6]. PPF-related pleural effusion should be distinguished from the reactive pleural effusion that occurs with pancreatitis that is usually left-sided and self-limiting.…”

“…However, it can occur on the right side (19%-40%) or bilaterally (14%-17%) [1]. Presenting symptoms are mainly pulmonary related, with dyspnea being the most common presenting symptom in 65%-76% of the cases [1][2][3][4][5][6]8,9]. Abdominal symptoms were reported in 24% of the cases.…”