A pancreaticopleural fistula is a rare cause of pleural effusion. It is a complication of chronic or acute pancreatitis. It is rarely formed to the right or both pleural cavities. Diagnosis and proper treatment often turn out to be difficult and require the cooperation of a multidisciplinary team. The authors present the case of a 59-year-old patient treated for recurrent pleural effusion of unknown origin, first to the left and then to the right pleural cavity. After many months of treatment, the diagnosis of a pancreaticopleural fistula was made. The patient underwent surgery, which finally led to a successful complete recovery. Pancreaticopleural fistula should always be considered in patients with pleural effusion of unknown origin.
Pancreatic fistula is an uncommon complication of acute or chronic pancreatitis. It develops as a result of pseudocyst rupture or pancreatic duct perforation. Most often, pancreatic secretions enter the peritoneal cavity and cause pancreatic ascites. Pancreaticopleural fistula formation is a very rare complication of chronic pancreatitis and even more rarely seen in acute pancreatitis [
We present a 59-year-old man, admitted to the Department of General, Endocrinological, and Gastroenterological Surgery in Poznań in September 2019 with chronic pancreatitis and suspicion of a pancreaticopleural fistula. The patient was hypertensive but denied smoking or alcohol use. Past medical history showed that the patient was healthy, quite athletic with no diabetes, tuberculosis, or chronic lung disease. Before admission to our department, the patient was hospitalized many times over the course of a year and treated for pleural effusions of unknown origin.
The patient’s medical history began with a sudden onset of chest pain radiating to the back. He presented to his outpatient clinic and was referred for a thoracic spine computed tomography (CT). Accumulation of fluid in the left pleural cavity was identified. The patient was referred to the pulmonary ward, already presenting with cough, moderate dyspnea, and a tightness on the left side of the chest. CT scan of the thorax and abdomen was performed which revealed fluid in the left pleural cavity, left lung atelectasis, and asymmetric thickening of the lower esophagus up to 26 mm, mainly on the left side. A note was also made of a 10 mm hypodense lesion in the pancreas tail. Using endoscopic ultrasound (EUS), the esophageal lesion was suspected to represent a Gastrointestinal Stromal Tumor (GIST), and material for cytological testing was collected through an EUS biopsy. A left thoracentesis was performed, and 1600 ml of bloody fluid was evacuated and sent for further cytological and microbiological tests. Only methicillin-susceptible S. epidermidis grew in the pleural sample: the patient was discharged home in good condition. After a week, he was readmitted because of increasing dyspnea. Due to the significant amount of reaccumulated fluid in the left pleura, a Robinson drain was placed in the left thoracic space. The patient was also referred to a gastroenterological outpatient clinic to follow up on the suspected esophageal GIST. During another scheduled hospitalization, videoscopic decortication of the left lung was performed. Lung expansion was achieved, but repeat CT scan showed an increase in the hypodense lesion in the pancreas tail. Histopathological examination of the pleura did not reveal any atypical cells. The patient was discharged home. After a month, he presented to the emergency department because of abdominal pain. Acute pancreatitis was diagnosed, and the patient was admitted to the general surgery department. The patient’s general condition and laboratory test results improved after the conservative treatment; therefore, the patient was discharged home with a pancreatic diet recommendation. In the outpatient clinic, an abdominal magnetic resonance imaging (MRI) (Figure
Magnetic resonance. Coronal and axial T2 single shot fast spin echo sequences revealed retroperitoneal peripancreatic fluid collections (a) extending to mediastinum (b) and free fluid in both pleural cavities (c). P: pancreas; F: fluid collection.
Magnetic resonance cholangiopancreatography. Coronal reconstruction. Normal caliber of bile and pancreatic ducts, no connection with fluid collections. Massive amount of free fluid in the right pleural cavity. White arrow: cholangiopancreatic ducts.
Computed tomography of chest cavity after intravenous contrast injection in axial plane. Free fluid in the right pleurum with atelectasis of the right lung and mediastinal shift.
Computed tomography of the abdomen after intravenous contrast injection in axial plane. Enhancement of fistulous track walls that connect peripancreatic fluid collection with right pleural cavity (a, b). Fistula is better seen after enlargement (c). P: pancreas; F: fluid collection.
Pancreatitis-related pleural effusions are rare complications of pancreatitis occurring in 3-7% of patients with pancreatitis. However, pleural effusion due to a pancreaticopleural fistula is very rare. Most authors rate the incidence of this complication as less than 1% [
The individual patient’s data used to support the findings of this study are available from the corresponding author upon request. Previously reported data are cited at relevant places within the text as References [
The authors declare that they have no conflicts of interest.