Pancreatic Pseudocyst Pleural Fistula in Gallstone Pancreatitis

Abstract

Extra-abdominal complications of pancreatitis such as pancreaticopleural fistulae are rare. A pancreaticopleural fistula occurs when inflammation of the pancreas and pancreatic ductal disruption lead to leakage of secretions through a fistulous tract into the thorax. The underlying aetiology in the majority of cases is alcohol-induced chronic pancreatitis. The diagnosis is often delayed given that the majority of patients present with pulmonary symptoms and frequently have large, persistent pleural effusions. The diagnosis is confirmed through imaging and the detection of significantly elevated amylase levels in the pleural exudate. Treatment options include somatostatin analogues, thoracocentesis, endoscopic retrograde cholangiopancreatography (ERCP) with pancreatic duct stenting, and surgery. The authors present a case of pancreatic pseudocyst pleural fistula in a woman with gallstone pancreatitis presenting with recurrent pneumonias and bilateral pleural effusions.

Figure 1

CT scan of the chest and abdomen demonstrating bilateral pleural effusions, the largest being in the left pleural cavity which is communicating directly with a pancreatic pseudocyst confirming the diagnosis of pancreatic pseudocyst-pleural fistula (PP-PF). Arrow A shows the position of the left pleural effusion communicating through fistula C with a large pancreatic pseudocyst D at the posterolateral aspect of the spleen B. Arrow E demonstrates the smaller right-sided pleural effusion.