Management of Rapidly Reaccumulating Pleural Effusion Secondary to Pancreaticopleural Fistula in a Nonsurgical Candidate

Document Type

Conference Proceeding

Publication Date

5-18-2025

Publication Title

Am J Respir Crit Care Med

Abstract

INTRODUCTION: Pancreaticopleural fistula (PPF) is a rare complication of chronic pancreatitis. Current treatment options include medical management with thoracentesis and octreotide, endoscopic retrograde cholangiopancreatography (ERCP) with stenting to close off the fistula tract, and pancreatic salvage surgery for fistula repair. We present a complicated case of PPF with rapidly re-accumulating pleural effusion and failed pancreatic stenting in non-surgical candidate. CASE: A 33-year-old man with past medical history of chronic alcoholic pancreatitis and severe malnutrition (body mass index 15.86) presented with dyspnea on exertion and pleuritic chest pain. Computed tomography (CT) showed large left-sided pleural effusion, complete collapse of the lung, and chronic pancreatitis. Thoracentesis revealed exudative fluid. Chest x-ray showed a small pneumothorax ex-vacuo and re-accumulation of pleural effusion. Magnetic resonance cholangiopancreatography (MRCP) showed a defect in the left diaphragmatic crura and a fistula from the pancreatic tail to the retro-crural region. Pleural effusion was initially managed with interval thoracentesis until chest tube placement. This was complicated by enlargement of the pneumothorax with lung collapse. ERCP demonstrated large ductal stones that precluded deep cannulation of the dorsal pancreatic duct, so the ventral pancreatic duct was accessed for stent placement. The large pneumothorax self-resolved, but the chest tube continued to have high output. Octreotide was started at 50 mcg every 8 hours for 1 day, then increased to 100 mcg every 8 hours, which resulted in decreased chest tube output over several days. He was discharged with the chest tube. Octreotide was discontinued on discharge, and he required several additional collection devices. Extracorporeal shockwave lithotripsy and ERCP with dorsal pancreatic duct stenting were planned outpatient for definitive management of the PPF. DISCUSSION: This case highlights multiple complexities of PPF treatment. Rapid re-accumulation of large-volume pleural effusions indicated a large fistula tract that required diversional stenting. Despite multiple ERCP attempts, large ductal stones in the pancreatic head prevented deep cannulation. Surgical intervention was considered, however severe malnutrition made him not a surgical candidate. Additionally, large volume drainage of exudative pleural effusion was complicated by a large pneumothorax ex-vacuo due to trapped lung pathology. Thoracic intervention was considered, however, the pneumothorax self-resolved. Due to high volume output from chest tube, octreotide was initiated for splanchnic vasoconstriction and resulted in reduced output. In patients who are not surgical candidates and fail endoscopic management, octreotide can be helpful in managing recurrent pleural effusion secondary to PPF, and further evaluation of efficacy is warranted.

Volume

211

First Page

1

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