From Pancreas to Pleura: Insights Into Pancreatic Fistula as a Result of Recurrent Pancreatic Inflammation

Document Type

Conference Proceeding

Publication Date

5-18-2025

Publication Title

Am J Respir Crit Care Med

Abstract

Introduction:Pleuro-pancreatic fistula (PPF) is a rare complication of chronic pancreatitis, involving anabnormal connection between the pancreatic duct and pleural space due to pancreaticinflammation. It typically presents with recurrent pleural effusions and pulmonary symptoms,often without overt pancreatic signs. Key indicators include a history of pancreatitis, significantweight loss, and pleural effusions or ascites unresponsive to diuretics.Case presentation:A 33-year-old male with a history of alcohol use disorder, chronic pancreatitis, pseudocystformation, and a pleuropancreatic fistula presented with worsening shortness of breath and chestpain. He had a recent large pleural effusion, with thoracentesis revealing pleural fluid pancreaticamylase at 300 U/L. Imaging showed a large left pleural effusion and new pancreatic cysticlesions. After thoracentesis and chest tube placement, a trapped lung was revealed. An attemptedERCP was complicated by pancreatic duct obstruction, but a stent was eventually placed. Hiscondition worsened due to ongoing fistula leakage, and a pancreaticoduodenal arterypseudoaneurysm was identified, requiring IR-guided embolization. He was transferred to atertiary hospital, where a mini atrium collecting system was placed for fluid drainage. He wasdischarged with a left chest tube and scheduled for outpatient follow-up.Discussion:Pleuro-pancreatic fistula (PPF) is a rare complication, occurring in less than 1% of acutepancreatitis cases and 4.5% of pancreatic pseudocyst cases, primarily linked to alcohol-relatedchronic pancreatitis. Diagnosis involves chest X-ray, CT scans, and thoracentesis, with pleuralfluid analysis showing high pancreatic amylase levels, often above 10,000 U/L. MRCP is thepreferred imaging modality for confirming the fistula. Treatment options include medicalmanagement with octreotide and TPN (31%-65% success), ERCP stenting, or surgery. Surgery ismost effective (94% success), particularly in cases where medical and ERCP treatments fail. The choice of treatment depends on imaging findings, with surgery indicated for complete duct-obstruction or disruption in the pancreatic tail.Conclusion:In conclusion, PF diagnosis relies on clinical suspicion, high pleural fluid amylase, and the imaging.,with treatment—medical, endoscopic, or surgical— determined by case specifics and a multidisciplinary approach.

Volume

211

First Page

1

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