P0137 - Pancreaticopleural Fistulas Manifesting as Rapidly Accumulating Pleural Effusions: Diagnosis and Management of Five Cases

Monica Dzwonkowski, DO, Shivani K. Desai, MD, Aastha Mittal, MD, Alejandra Perez-Chapman, DO, Raghuveer Puttagunta, MD, David L. Diehl, MD, Bradley D. Confer, DO, Prakash Kharel, MD
Geisinger Medical Center, Danville, PA

Introduction: Pancreaticopleural fistula (PPF) is a rare but serious complication of pancreatitis, occurring in only 0.4% of patients with pancreatitis. Many patients present with primarily respiratory complaints including dyspnea, cough, and chest pain secondary to pleural effusions rather than abdominal symptoms which can lead to delayed diagnosis. Demonstration of high amylase in pleural fluid is a key component of diagnosing PPF. Treatment includes pancreatic stenting and sphincterotomy via endoscopic retrograde cholangiopancreatography (ERCP), which alters the transpapillary gradient toward the duodenum to facilitate closure of the defect. We present five patients who presented to a large regional integrated healthcare system with respiratory complaints who were found to have rapidly accumulating pleural effusions that were diagnosed with pancreaticopleural fistulas.

Case Description/Methods: Five patients (one female, four male) spanning from 2008 to 2022 were admitted with respiratory complaints including dyspnea and cough (Table 1). All five patients were found to have new or recurrent pleural effusions on imaging and underwent thoracentesis. Pleural fluid analysis revealed incalculable high amylase ( >7.5k U/L) in four patients. The last patient had an initial amylase level of 508 U/L, but imaging revealed a subdiaphragmatic connection suggestive of PPF and ERCP demonstrated contrast extravasation through a defect in the pancreatic duct. Four of the five patients had a history of pancreatitis, whereas one patient had a unique presentation with a history of trauma to his chest one month prior to hospital admission but no history of pancreatitis. All five patients were treated successfully via placement of a pancreatic duct stent via ERCP. Two of the five are now deceased for reasons unrelated to their PPF.

Discussion: Diagnosis of PPF requires a high index of suspicion as patients present with primarily respiratory complaints. Though the condition is rare, patients who require several thoracenteses due to recurrent pleural effusion should raise suspicion for PPF and prompt analysis of pleural fluid for amylase. If amylase levels are high, the next step in diagnosis is confirmation of a fistula via MRCP, ERCP, or CT scan. ERCP can be both diagnostic and therapeutic and thus was the modality chosen for our patients which led to recovery. MRCP with secretin enhanced protocol may be considered in cases that have lower suspicion for fistula or those with minimally elevated amylase.



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Monica Dzwonkowski, DO, Shivani K. Desai, MD, Aastha Mittal, MD, Alejandra Perez-Chapman, DO, Raghuveer Puttagunta, MD, David L. Diehl, MD, Bradley D. Confer, DO, Prakash Kharel, MD. P0137 - Pancreaticopleural Fistulas Manifesting as Rapidly Accumulating Pleural Effusions: Diagnosis and Management of Five Cases, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.