대한흉부영상의학회 Weekly Chest Cases

Case No : 1321 Date 2023-02-13

Courtesy of Kang Heon Lee, Kyung Hee Lee / Inha University Hospital
Age/Sex 47 / M
Chief ComplaintDyspnea, Left chest pain

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Figure 5

Diagnosis With Brief Discussion

Diagnosis: Pancreaticopleural fistula
Radiologic Findings: Fig 1. Chest PA shows massive left pleural effusion with mediastinal shifting to right.
Fig 2. CT scan shows minimal peripancreatic infiltration and pseudocyst formation in tail of pancreas.
Fig 3-5. Massive amount of left pleural effusion with passive atelectasis of left lung is seen. Pseudocyst is extending into hiatal area,
On pleural fluid analysis, amylase was increased. 603 IU/ L. (serum amylase 112 IU/L)
Brief Review: 1.Introduction
Pancreaticopleural fistulas(PPF) are a rare complication of acute or chronic pancreatitis whereby enzymatic pancreatic fluid, either from a pancreatic pseudocyst or directly from a disrupted duct dissects into the pleural cavity. It can occur as a result of acute or chronic pancreatitis, trauma, iatrogenic pancreatic duct disruption, and congenital anomalies of pancreatic duct.
PPFs are thought to develop from leakage from ruptured pseudocyst or direct pancreatic duct leakage into pleural space via aortic/esophageal hiatus or through diaphragm. They may also erode the pleural lining and disrupt subpleural vessels, causing bleeding into pleural space

2.Clinical manifestation
PPFs are seen predominantly in alcoholic middle-aged men, but only half of them have clinical histories of previous pancreatitis. Biliary obstruction is more common etiology in children.
Pleural effusions are more commonly seen in the left side.(~75%)

3. Diagnosis
Diagnosing PPF needs high clinical suspicion. Diagnosis can be established via thoracentesis with pleural fluid analysis, demonstrating exudative effusion with high amylase level. There is no definite cut-off point for amylase level, but typically it is above >1,000 IU/L and commonly above 10,000 IU/L. Other causes of amylase-rich pleural effusions include parapneumonia effusion, TB, esophageal rupture and malignancies like leukemia, lymphoma and gynecologic malignancies. But only PPF related effusions have the pancreatic-type amylase; other causes of amylase-rich pleural effusion will have the salivary type amylase of pleural effusion. It is confirmed by amylase isoenzyme analysis.

4. Radiologic feature
-Sensitivity of various imaging modalities to delineate the fistulous track.
CT: 47%, ERCP: 78%, MRCP: 80%
-CT
Peripancreatic fluid collections were located along the fistulous tract that ascending upwards crossing diaphragm(mainly through hiatus) to the pleural cavity causing pleural effusion.

-ERCP
It can be diagnostic and therapeutic at the same time. However, it is 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

-MRCP
Noninvasiveness, possibility to detect the fistula even in case of severe strictures of the pancreatic duct

5.Treatment and prognosis
Initial management of PPF include reduction of pancreatic stimulation with NPO and octreotide(a long-acting somatostatin analogue) to decrease pancreatic secretion. Medical treatment is successful in 31~65% of cases. However, it needs two to three weeks of medical treatment and it is often conjugated with chest tube placement or PCD to place the recurrent pleural effusion in that period.
Conservative therapy is often unsuccessful, and endoscopic transpapillary nasopancreatic drain or endoscopic pancreatic stent is frequently required.
Surgical treatment if the last resort when medical and ERCP treatment fail. The main principle of surgical treatment is to form a pancreatic enteric connection to achieve adequate drainage of the pancreatic sections with or without pancreatic resection. The most common surgery reported in the treatment of PPF is distal pancreatectomy with pancreaticojejunostomy.
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

No. of Applicants : 98

▶ Correct Answer : 56/98, 57.1%

- , Japan SUZUNE TSUKAMOTO
- ZIGONG TCM HOSPITAL OF CHINA , China CAO CUN YOU
- , Japan KYOKO NAGAI
- Niigata University , Japan ATSUSHI UEHARA
- Shiga University of Medical Science , Japan AKITOSHI INOUE
- Hospital of Sacred Heart, Montreal , Canada ANDREA OJANGUREN
- Kyoto City Hospital , Japan YUSUKE UTSUNOMIYA
- Seoul National University Hospital , Korea (South) HYUNGIN PARK
- , Italy PAOLO BALDASSARI
- Tiger Gate Hospital , Japan SHIN-ICHI CHO
- , Japan CHIAKI SATO
- Other , Korea (South) HWANGHEE JO
- Vita Hospital , Brazil DIOGO LAGO PINHEIRO
- Other , Korea (South) SEONGSU KANG
- Scans world , India PHILSON JOSEPH MUKKADA
- Korea University Guro Hospital , Korea (South) YEJU KANG
- , Korea (South) JIN YOUNG LEE
- , China FANG YING GEN
- Seoul Medical Center , Korea (South) HYUK GI HONG
- The University of Tokyo Hospital , Japan WATARU GONOI
- university of montreal , Canada Andrei Bogdan Gorgos I
- Osaka University , Japan AKINORI HATA
- Korea University Guro Hospital , Korea (South) HEEJUN PARK
- , Japan HIKARI FUKUI
- Ajou University Hospital , Korea (South) HAEIN LEE
- , Korea (South) MINJI KIM
- Soonchunhyang University Hospital Bucheon , Korea (South) HYEJOO PARK
- , Korea (South) CHAE YOUNG SHIN
- Ajou University Hospital , Korea (South) HYUNSEUNG LEE
- The University of Tokyo Hospital , Japan TOSHIHIRO FURUTA
- Ajou University Hospital , Korea (South) JAYOUNG MOON
- Gifu University Hospital , Japan Yo Kaneko
- Kyoto University Hospital , Japan YASUHISA KURATA
- Ajou University Hospital , Korea (South) YOU NA KIM
- University of Tsukuba, Dept of Radiology , Japan MANABU MINAMI
- Avrasya Hospital/ISTANBUL , Turkey MURAT ULUSOY
- , Qatar NABIL SHERIF MAHMOOD
- Korea University Guro Hospital , Korea (South) LEE DAKYONG
- Other , Korea (South) SEONG WON JANG
- Dokkyo Medical University , Japan HIROAKI ARAKAWA
- Manipal hospital Hebbal, Bengaluru , India PRAVIN KUMAR M
- Seoul National University Hospital , Korea (South) SUNGHO HONG
- Korea University Anam Hospital , Korea (South) KYU-CHONG LEE
- Paras hospital, Panchkula , India SHALEEN RANA
- Hyogo Prefectural Kobe Children , Japan SHUHEI NORIMOTO
- Seoul National University Bundang Hospital , Korea (South) YOONAH DO
- Yonsei University,Severance Hospital , Korea (South) SEO BUM CHO
- Toranomon Hospital , Japan KAORU SUMIDA
- Ichinomiya Nishi Hospital , Japan Takao Kiguchi
- Nerimahikarigaoka hospital , Japan TAKANA HAYASHI
- Matsunami General Hospital , Japan TARO TAKEDA
- , Japan YUMI MAEHARA
- Shiga University of Medical Science , Japan RYO UEMURA
- , Japan YUKI HAYASHI
- The Catholic University of Korea Yoeuido St. Mary , Korea (South) CHAWOONG JEON
- Kyoto university , Japan AKIHIKO SAKATA

▶ Correct Answer as Differential Diagnosis : 5/98, 5.1%

- Saitama-Sekishinkai Hosptal , Japan MIHOKO YAMAZAKI
- Narayana Multispeciality Hospital Jaipur Rajasthan , India JAINENDRA JAIN
- Jichi Medical University, School of Medicine , Japan MITSURU MATSUKI
- Chonnam National University Hospital , Korea (South) KIM SANG GYUN
- Chonnam Hospital , Korea (South) JAEHYUN PARK

▶ Semi-Correct Answer : 29/98, 29.6%

- Ishikawa Matto Central Hospital , Japan MANABU AKIMOTO
- Wakayama Red Cross Hospital , Japan TOMOAKI OTANI
- , Japan HIROAKI ARAKAWA
- Jichi Medical University Hospital , Japan JUN KANZAWA
- McGill University Health Center , Canada ALEXANDRE SEMIONOV
- National Center of Neurology and Psychiatry , Japan MOTO NAKAYA
- Oita University, Faculty of Medicine , Japan FUMITO OKADA
- Samsung Medical Center , Korea (South) JUHYUN KIM
- Qatif Central Hospital , Saudi Arabia HANI MAKKY ALSALAM
- Kaneda hospital , Japan HIROFUMI MIFUNE
- Shimada General Medical Center , Japan HAYATO NOZAWA
- Yamanashi Prefectural Central Hospital , Japan HIROAKI WATANABE
- Inje University Pusan Paik Hospital , Korea (South) JIYEON HAN
- Hukuda memorial hospital , Japan SHINTARO KANO
- , Japan KENTARO KOTANI
- Osaka Metropolitan University Hospital , Japan SHU MATSUSHITA
- Chungbuk National University Hospital , Korea (South) MIHYEON PARK
- Osaka metropolitan university Hospital , Japan TATSUSHI OURA
- Chonnam National University Hospital , Korea (South) SEOLBIN PARK
- Others , India PURUSHOTHAMA RAO TUMMALA
- Nishida Hospital , Japan SHOJI OKUDA
- Kyoto University , Japan SHO KOYASU
- University of Tsukuba Hospital , Japan SODAI HOSHIAI
- Chonnam National University Hospital , Korea (South) SOMIN LEE
- Chonbuk National University Hospital , Korea (South) DONG HAN SHIN
- , Japan NOBUYUKI OTANI
- the first affiliatited hospital of nanjing medical univercity , China HAI XU
- Juntendo University , Japan YUTAKA IKENOUCHI
- Jiangsu province hospital , China WANGJIAN ZHA

대한흉부영상의학회 Korean Society of Thoracic Radiology

Cases by Disease Category

Case No : 1321 Date 2023-02-13

Discussion

No. of Applicants : 98