Pancreaticopleural fistula – An unusual indication of intercostal tube drainage

Pancreaticopleural fistula

Abstract

Pancreatitis, whether acute or chronic, can lead to a spectrum of local and systemic complications due to the extravasation of inflammatory mediators in the vicinity of the gland. One such rare complication is the development of a pancreaticopleural fistula (PPF), typically presenting as a unilateral or, less commonly, bilateral pleural effusion accompanied by respiratory symptoms. A young male in his thirties with a history of heavy alcohol consumption presented with dyspnea, upper abdominal pain, and a recent episode of an alcohol binge, one month ago. Clinical examination revealed epigastric tenderness in the epigastrium with decreased breath sounds, and a diagnosis of acute pancreatitis was made. This was confirmed by elevated serum lipase and bilateral pleural effusion on chest X-ray. Given his partial response to conservative management, a decision was taken for bilateral tube thoracostomy. Fluid analysis confirmed the diagnosis of PPF. He was subsequently started on somatostatin analogs and parenteral nutrition. He responded well to the above treatment and was discharged after a week. While PPF is a recognized cause of unilateral pleural effusion, bilateral involvement is uncommon. The condition often presents predominantly with chest symptoms, with a paucity of abdominal complaints. It should be suspected that alcoholic pancreatitis responds poorly to usual conservative therapy. The biochemical analysis of the aspirated pleural fluid reveals significantly increased amylase levels, which clinches the diagnosis. Cross-sectional imaging helps in characterizing the primary disease in the pancreas and in delineating the ductal anatomy. Endoscopy is both diagnostic and therapeutic, as it involves placing a stent in the main pancreatic duct (MPD). The management involves a combination of medical, endoscopic, and surgical modalities. Medical management is successful in a majority of cases by using somatostatin analogs with nutritional support. Placement of an intercostal tube hastens recovery and reduces the duration of hospitalization. Surgical management by distal pancreatectomy with pancreatojejunostomy is reserved for a small subset of patients. Hence, patients with PPF rarely present with bilateral pleural effusion and are an indication for tube thoracostomy with successful results.