SHM Converge Scientific Abstract ePoster Gallery-Pancreaticopleural Fistula: A Rare Presentation of Bilateral Pleural Effusions and Trapped Lung

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This case report describes a rare presentation of pancreaticopleural fistula (PPF) causing large bilateral pleural effusions and trapped lung in a 41-year-old woman with long-standing alcoholic chronic pancreatitis and hepatitis C. She presented with three days of dyspnea on exertion, orthopnea, right-sided chest pain, tachypnea, and mild hypoxia. Chest x-ray showed a large left pleural effusion and moderate-to-large right pleural effusion.<br /><br />Thoracentesis removed 1.55 L of bloody, serosanguinous fluid. Pleural fluid studies showed elevated amylase and lipase, supporting a pancreatic source, though the amylase level was lower than is typical for PPF. CT imaging revealed a dilated pancreatic duct and a stable pancreatic pseudocyst, along with a large left hydropneumothorax and persistent right pleural effusion. After drainage, the patient developed findings consistent with trapped lung and ex vacuo pneumothorax.<br /><br />Because of the trapped lung, she underwent left VATS decortication. Pleural biopsy showed inflammation, fibrosis, and abscess formation. Recurrent right-sided loculated effusion required chest tube placement, followed by a second left chest tube when fluid reaccumulated. Gastroenterology then performed EUS and ERCP. EUS did not show malignancy, while ERCP demonstrated a dilated pancreatic duct with leakage near the tail/upstream body, confirming a likely pancreaticopleural fistula. A pancreatic sphincterotomy and plastic stent were placed to reduce pancreatic duct pressure and allow the fistula to close.<br /><br />After endoscopic treatment, the bilateral pleural effusions improved and did not recur, allowing chest tube removal. The authors emphasize that PPF should be considered in patients with persistent pleural effusions, even bilateral ones, especially in those with a history of pancreatitis. Pleural fluid amylase testing and diagnostic imaging with ERCP or MRCP are key to diagnosis, and endoscopic stenting can be effective treatment.

Asset Subtitle

Myra Ali

Meta Tag

Author List Aileen Bui, Amanda Cruz, Arnold Tsai, Jin Sun Kim, Jose Gonzalez, Kevin Zhang, Madeline Macdonald, Myra Ali

Category Clinical Vignettes

Concept Pancreaticopleural Fistula

Concept Chronic Pancreatitis

Concept Pleural Effusion

Concept Pleural Fluid Amylase

Concept Trapped Lung

Distinguished Non-Finalist

Presenter Organization Keck School of Medicine of USC

Presenting Author Myra Ali

Track Adult

Keywords

pancreaticopleural fistula

pleural effusion

chronic pancreatitis

trapped lung

thoracentesis

pleural fluid amylase

ERCP

EUS

pancreatic duct leak

endoscopic stenting

Pancreaticopleural Fistula

Chronic Pancreatitis

Pleural Effusion

Pleural Fluid Amylase

Trapped Lung