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CASE REPORTS
RIGHT SIDED PANCREATICO PLEURAL FISTULA : A RARE CLINICAL PRESENTATION
JIGNESH A GANDHI, APARNA A DESHPANDE, GURUPRASAD SHETTY, JAIPRAKASH V HARDIKAR
Pancreatico-pleural fistula secondary to chronic pancreatitis is a rare cause of pleural effusion.1 Traditionally the treatment for internal pancreatic fistulae is surgical.2 However with advances in endotherapy, pancreatic duct stenting has been used as an alternative form of therapy for internal fistulae.2 We present a report of a patient with chronic pancreatitis presenting with breathlessness secondary to pancreatico-pleural fistula which was treated by pancreatic duct stenting.
CASE REPORT37 year old male, chronic alcoholic, who was a known case of chronic pancreatitis presented with sudden onset cough, dyspnoea and right sided chest pain. On physical examination the patient had upper abdominal pain with minimal tenderness, dyspnoea with reduced air entry on right side. Radiograph of the chest revealed massive right sided pleural effusion. Diagnostic pleural tapping revealed a serosanguinous fluid, which on examination turned out to be an exudates. No organisms were grown. The Adenosine deaminase values were normal and no malignant cells were seen. Amylase levels of pleural fluid was 1,33,000 IU/L Computed tomography (CT) scan of the chest and abdomen showed a massive pleural effusion, parenchymal atrophy of pancreas, a pancreatic duct dilatation and pancreatic calcification.
Patient was treated conservatively with total parenteral nutrition, octreotide 50 micrograms 8 hrly for 7 days. Therapeutic tapping of about 1.5 litres of pleural fluid was performed on 2 occasions to relieve respiratory embarrassment. There was recurrence of the pleural fluid within 48 to 72 hrs which was confirmed on serial radiographs. With the above information a diagnosis of pancreatico-pleural fistula was made.
Patient did not improve with adequate conservative line of treatment administered for a period of ten days. Hence an Endoscopic retrograde pancreatography with stenting was contemplated as a therapeutic option. Endoscopic retrograde pancreatography (ERP) revealed a stenosis at the distal pancreatic duct with a proximal fistulous tract communicating superiorly on the right side towards the pleural cavity confirming our diagnosis of right pancreatico-pleural fistula (Fig. 1). The pancreatic duct was stented with a 7 French Stent. Post stenting the patient improved clinically with regression of pleural effusion within 2 days which was confirmed on chest X-ray.The patient was given a course of antibiotics and octreotide 50 micrograms for 5 days and pancreatic enzyme supplementation. The patient remained asymptomatic for the next 2 months with complete resolution of the pleural effusion. At the end of 8 weeks, the pancreatic stent was removed and the patient continued to do well. At the last follow up of 2 months, patient was asymptomatic.
DISCUSSION
Pancreatic ascites and pancreatico pleural effusion are infrequent complications of chronic pancreatitis. They are more commonly seen with acute pancreatitis.1 Pleural effusion are reported to occur in 4 to 17% of patients of chronic pancreatitis.
In this report we present right sided pleural effusion occurring as an isolated complication of chronic pancreatitis.
The pleural effusions are reported to be large and recurrent, and arise from fistulous tract between pancreas and pleural cavity with or without pseudocyst formation.3 It usually predominates on left side, and has been occasionally reported bilaterally or on the right side. The internal fistula results from leakage of pancreatic secretion posteriorly through a leak in the pancreatic duct, with the pancreatic secretion migrating through the retroperitoneum up into the mediastinum. The pleural fluid is typically exudate with a high amylase level. 3 Clinical presentation, radiographic studies and determination of high fluid amylase level usually confirms the diagnosis
Initial therapy of internal pancreatic fistula should be non-operative.4 The medical management has been successful in 43% to 81% of patients according to various series.5,6 However high mortality rate has been reported when medical management was continued for more than 2 weeks.4 In our patient, medical management including octreotide and symptomatic treatment of the effusion by pleural tapping on two occasions was instituted and continued for 10 days. This was not effective as patient had repeated episodes of breathlessness due to rapid re-accumulation of the fluid with drop in oxygen saturation. This forced us to take an early decision for endoscopic retrograde pancreatography and stenting with internal drainage.
CONCLUSION
Pancreatico-pleural fistulae are less common with patients with chronic pancreatitis. The effusion is often large leading to respiratory distress. It is more frequent on the left side and has been reported infrequently on the right side. ERP and CT have been used for diagnosis of fistulae. Pancreatic stenting helps in internal drainage of pancreatic fluid and regression of pleural effusion with healing of the fistula. Surgical intervention is a definitive treatment in a recurrent pancreatico-pleural fistula.
REFERENCES
1. Matrene R, Deprez P. Pancretico-pleural fistula. Chest 2000; 117 : 912-14.
2. Saeed ZA, Ramirez FC. Endoscopic stent placement for internal pancreatic fistulas. Gastroenterology 1993; 105 :
1213-7.
3. Edurado J, Machado M. Surgical treatment of Pancreatic Ascites and Pancreatic pleural fistula. Hepatogastroenterology 1995; 32 : 748-51.
4. Lipsett PA, Cameron JL. Internal pancreatic fistulas. American Journal Surgery 1992; 163 : 216-20.
5. Parekh D, Segal I. Pancreatic Ascites and Pleural effusions. Role of Octreotide. Archives Surgery 1992; 127 : 7070-712.
6. Cameron JL, Kieffer RS. Internal Pancreatic Fistulas. Annals Surgery 1976; 184 : 587-93.
PREVALENCE OF H. PYLORI IS LOWER IN PATIENTS WITH REFLUX DISEASE
Patients with gastro-oesophageal reflux disease have a lower prevalence of Helicobacter pylori infection than patients without this disease. Raghunath and colleagues conducted a systemic review of the medical literature and contacted experts and pharmaceutical companies, and identified 20 studies. On average, H. pylori infection was present in 39% of patients with reflux disease and in 50% of the patients without the disease. Location seems to be another important determinant: the prevalence of H. pylori infection in patients with reflux disease is much lower in the Far East, despite a higher prevalence in the general population, than in North America and Western Europe.
BMJ, 2003; 326 : 737.
