P0112 - Pancreatic Pleural Fistula Presenting as Large Bilateral Pleural Effusions Without Known History of Pancreatitis

Mako Koseki, MD¹, Gres Karim, MD², Caileen Sennett, MD², Kevin Jordan, MD^2
1Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, NY; ²Mount Sinai Beth Israel, New York, NY

Introduction: Pancreatic pleural fistula (PPF) is a rare complication of acute and chronic pancreatitis, characterized by leakage of pancreatic secretions into the thorax, resulting in pleural effusions. While the incidence of pancreatitis-related pleural effusion is low, estimated at 3-7%, PPF is even rarer, with an estimated incidence of 1%. It is atypical for PPF to be diagnosed in patients without a documented history of pancreatitis. This report describes a case of a middle-aged man who presented with dyspnea and was found to have large bilateral effusions secondary to PPF, despite having no recent episode of pancreatitis.

Case Description/Methods: A 48-year-old man with a past medical history of treated hepatitis C infection and remote alcohol use disorder presented with a one-month history of dyspnea, dry cough, and chest discomfort. Chest x-ray revealed bilateral pleural effusions with nearly complete opacification of the left lung fields. Computed tomography (CT) angiography showed a 1.4 x 1.1 cm rim-enhancing fluid collection arising from the pancreatic tail, ascending upward and posteriorly. A diagnostic and therapeutic thoracentesis provided significant relief of symptoms after removal of two liters of dark serosanguinous fluid, which was exudative with a high amylase level of 1703 U/L. Magnetic resonance cholangiopancreatography (MRCP) was obtained to identify a unifying diagnosis. It revealed a fluid-filled tract extending from the tail of the pancreas to the left pleural space, concerning for a PPF. The patient underwent endoscopic retrograde cholangiopancreatography (ERCP) with successful stent placement after a stenosis of 10mm in length was observed in the proximal pancreatic duct with upstream duct dilation.

Discussion: PPF typically presents with a recent history of pancreatitis and may cause cough and dyspnea due to pleural effusions (Table 1). However, in this case, the patient had no documented history or symptoms of pancreatitis, making the diagnosis of PPF challenging. It is important to consider PPF in patients with even a history of alcohol use disorder presenting with dyspnea and pleural effusions. Prompt treatment with ERCP or surgery is necessary, as recurrence of pleural effusions can be prevented with success rates of over 90%.




Disclosures:


Mako Koseki, MD¹, Gres Karim, MD², Caileen Sennett, MD², Kevin Jordan, MD². P0112 - Pancreatic Pleural Fistula Presenting as Large Bilateral Pleural Effusions Without Known History of Pancreatitis, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.