Abstract Background Pancreaticopleural Fistula (PPF) is a rare complication of pancreatitis, occurring in less than 1% of cases. It results from pancreatic duct disruption or pseudocyst rupture, allowing enzyme-rich secretions to enter the pleural space. Respiratory symptoms usually predominate, hence pulmonologists are usually the first to evaluate these patients. Recognition of PPF is essential to preventing misdiagnosis and unnecessary interventions. Case Summary A 47-year-old man with a history of alcohol use disorder, recurrent acute pancreatitis, and necrotizing pancreatitis presented with progressive shortness of breath and unintentional weight loss. Chest imaging revealed a massive left pleural effusion causing near complete left lung collapse and rightward mediastinal shift. Chest tube drainage yielded about 4L of bloody fluid within 24 hours. Fluid analysis revealed markedly elevated pleural fluid amylase (25,995 U/L). Magnetic Resonance Cholangiopancreatography (MRCP) demonstrated a pancreatic pseudocyst with a fistulous tract communicating with the left pleural space, confirming a PPF, without main pancreatic duct disruption. The patient was managed conservatively with chest tube drainage, bowel rest, parenteral nutrition, and the somatostatin analogue, Octreotide. Endoscopic Retrograde Cholangiopancreatography (ERCP) was deferred due to anatomical considerations. Pleural effusion was loculated; however, intrapleural fibrinolytics were deferred due to bleeding risk. After two weeks of conservative management, repeat MRCP showed closure of the fistulous tract. The patient was then discharged to outpatient pulmonology and gastroenterology follow-up. Conclusion PPF should be considered in patients presenting with massive or recurrent pleural effusions, particularly when pleural fluid amylase and/or lipase are markedly elevated. Early recognition and multidisciplinary management, pleural fluid drainage, and conservative therapy with or without endoscopic intervention can achieve fistula closure while minimizing morbidity. In select patients, with failure of conservative treatment or large pseudocysts, surgical intervention is warranted. This abstract is funded by: None
Igbokwe et al. (Fri,) studied this question.