대한흉부영상의학회 Korean Society of Thoracic Radiology

Discussion

Diagnosis With Brief Discussion

Diagnosis

Pancreaticopleural fistula

Radiologic Findings

Chest AP shows loculated effusion in right upper hemithorax.
Chest CT scans show empyema in Rt hemithorax and loculated fluid in upper abdomen with fistula tract between retrocrural space and abdomen.
Abdomen CT(below) reveals pancreatitis and pancreatic pseudocyst.
On pleural fluid analysis, amylase was increased 4800 U/L.

Brief Review

1.Introduction
-Abnormal communication between the pancreas and pleural cavity
-Cause: leakage of pancreatic secretion from damaged ducts, leakage from pancreatic pseudocyst, trauma (less common, 0~5% of reported cases)
-Unusual complication of chronic pancreatitis (0.4% of patients with chronic pancreatitism and 4.5% of patients with pancreatic pseudocyst)
-Possible mechanism of pathogenesis
Leakage from ruptured pseudocyst or direct pancreatic duct leakage --> pancreatic enzymes entering into chest erode the pleural lining and disrupt subpleural vessels --> bleeding into pleural space

2.Clinical manifestation
-Predominantly present in alcoholic middle-aged men (only half of them have clinical histories of previous pancreatitis)
-Lt. pleural effusion (51%), Rt. (32%), bilateral (16%)
-Diagnosis
i.Markedly elevated amylase in the pleural fluid: most important (>1,000 IU/L, protein >3.0 g/dL), commonly show several thousand units
(ddx.> malignancy, esophageal perforation)
ii.Amylase isoenzyme analysis: ~100% pancreatic amylase
iii.Serum amylase: usually mildly elevated

3. Radiologic feature: ERCP and CT will identify actual fistulous tract in 70%
-CT
Peripancreatic fluid collections were located along the fistulous tract that dissected into the mediastinum through esophageal or aortic hiatus

-MRCP
Method of choice for suspected PPF, sensitivity 80%
Noninvasiveness, possibility to detect the fistula even in case of severe strictures of the pancreatic duct
-ERCP
2nd. Effective modality to diagnose PPF, sensitivity 46-78%
Invasive, but possible simultaneous endoscopic treatment
Ineffective in anatomic anomalies of pancreatic ducts, severe ductal strictures or obstructions
Value of ERCP may improved by performing CT scan after endoscopy to determine the course of fistula filled with contrast medium

4.Treatment and prognosis
-Conservative management: control of pleural effusion (intercostals tube drainage), NPO, octreotide acetate
48% fistula closure over a 2-3 week period
-Transpapillary nasopancreatic drain (fails to heal within 2-3 weeks)
-Surgical treatment: depending on the local anatomy, distal pancreatectomy, pancreatojejunostomy of fistula closure via transthoracic approach

References

1.Takashi Fujiwara, Terumi Kamisawa, Junko Fujiwara, Yuyang Tu, Hitoshi Nakajima, Naoto Egawa. Pancreaticopleural fistula visualized by computed tomography scan combined with pancreatography. Journal of pancreas 2006;7(2):230-233
2.Norman Oneil Machado. Pancreaticopleural fistula; revisited. Diagnostic and therapeutic endoscopy, 2012, article ID 815476, 5 pages
3.Hesham El-Beialy, Ivo Fernandez. Unusual case of persistent unilateral pleural effusion secondary to pancreaticopleural fistula. International journal of surgery case reports 2012;3:435-436
4.Shiro Sonoda, Miki Taniguchi, Tomohide Sato, Motohisa Yamasaki, Megumu Enjoji, Sunao Mae, Tetsuya Irie, et al. Bilateral pleural fluid caused by a pancreaticopleural fistula requiring surgical treatment. International medicine, 2012;51:2655-2661
5.Young S. OH, Steven A.Edmundowicz, Sreenivasa S.Jonnalagadda, Riad R.Azar. Pancreaticopleural fistula: report of two cases and review of the literature. Digestive diseases and sciences, 2006;51:1-6
6.Marek Wronski, Maciej Slodkowski, Wlodzimierz Cebulski, Daniel Moronczyk, Ireneusz W Krasnodebski. Optimizing management of pancreaticopleural fistulas. World journal of gastroenterology, 2011;17(42):4696-4703

Keywords

Pleura, Non-infectious inflammation,