Right-sided pancreaticopleural fistula.

Pancreaticopleural fistula (PPF) is a rare complication of chronic pancreatitis due to communication of the pleural cavity (usually the left) with the pancreatic duct [1-5]. In contrast to fistulization, pleural effusion associated with acute pancreatitis is usually small, left-sided and described as either chemically-induced, sympathetic in nature, or due to the diffusion of pancreatic enzymes through diaphragmatic lymphatics.

We report the case of a 47-year-old alcoholic male with a history of chronic pancreatitis, who was admitted because of non-productive cough, dyspnea and orthopnea. Chest x-ray examination (Fig. 1A) and chest computed tomography (CT) revealed a large right pleural effusion (Fig. 1B) and flocking pancreatic calcifications. A chest drain was inserted and 3.8 L of exudative polymorphonuclear fluid with amylase 34455 U/mL were drained. Magnetic resonance cholangiopancreatography (MRCP) examination (Fig. 1C) showed chronic pancreatitis and PPF, and endoscopic retrograde cholangiopancreatography (ERCP) imaging revealed a pancreatic duct with characteristics of chronic pancreatitis and upper part communication with the pleural cavity (Fig. 1D). Initially, we performed pancreatic sphincterotomy. Guide wire catheterization with subsequent balloon cleansing produced secretions. Finally, after a pig tail stent was inserted and somatostatin was prescribed, the health of the patient improved. A second MRCP showed partial closure of the fistula (Fig. 1E) and undetectable amylase in the pleural effusion. The patient is in good health 18 months after endoscopic treatment. No pathological findings were detected in a recent chest CT. A second ERCP was not needed since the pancreatic stent was automatically rejected.

Figure 1

(A) A chest x-ray examination showing a right pleural effusion. (B) A chest computed tomography showing a right pleural effusion. (C) Communication of the pancreatic duct with the pleural cavity on magnetic resonance cholangiopancreatography (MRCP) imaging. (D) The pleuropancreatic fistula on endoscopic retrograde cholangiopancreatography imaging. (E) The pleuropancreatic fistula partially closed on MRCP imaging

Therapeutic treatment of PPF consists of administration of somatostatin [1] and endoscopic drainage with pancreatic sphincterotomy and stenting of the pancreatic duct [1]. However, this approach is not always possible and the patients are subject to surgical treatment [6].

In conclusion, this case reminds us that PPF is associated rarely with right pleuritis and endoscopic treatment with somatostatin infusion can be effective.