SHM Converge Scientific Abstract ePoster Gallery-Pancreaticopleural Fistula Presenting as Empyema

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This case describes a 61-year-old man with chronic pancreatitis, alcohol use disorder, and recurrent hospitalizations for acute-on-chronic pancreatitis, complicated by large pancreatic pseudocysts requiring cystogastrostomy. He presented with shortness of breath, pleuritic chest pain, fever, tachycardia, hypoxemia, and absent breath sounds on the left. Chest X-ray and CT showed a massive left pleural effusion with loculations, raising concern for empyema.<br /><br />Emergent thoracentesis yielded 2 liters of purulent-appearing fluid. Initial pleural studies were highly inflammatory, with very low pH, extremely high LDH, marked leukocytosis, and low glucose, supporting the impression of empyema. He was started on broad-spectrum antibiotics. However, further testing revealed pleural fluid lipase >3,000 U/L and amylase 7,500 U/L, which strongly suggested a pancreatic source. Although MRCP was unrevealing, the ongoing rapid reaccumulation of pleural fluid kept suspicion high. ERCP ultimately demonstrated a small pancreaticopleural fistula connecting a pancreatic pseudocyst to the left hemithorax.<br /><br />The patient was managed with bowel rest, total parenteral nutrition, octreotide, and repeat ERCP with stent placement, after which he improved and was discharged in stable condition.<br /><br />The discussion emphasizes that pancreaticopleural fistula is a rare but potentially life-threatening cause of pleural effusion, often arising from pancreatic pseudocysts in patients with recurrent pancreatitis. It can mimic empyema on imaging and pleural fluid analysis. Markedly elevated pleural fluid amylase and lipase help distinguish it from infectious pleural effusions, and diagnosis may require MRCP or ERCP. This case highlights the importance of including pancreaticopleural fistula in the differential diagnosis of large unilateral pleural effusions in patients with a history of pancreatitis.

Asset Subtitle

Steven Koller

Meta Tag

Author List Devesh Kumar, Roshan Thapa, Steven Koller, Valerie Carter

Category Clinical Vignettes

Concept Pancreaticopleural Fistula

Concept Pleural Effusion

Concept Pleural Fluid

Concept Amylase

Concept Pancreatitis

Distinguished Non-Finalist

Presenter Organization Medical College of Wisconsin

Presenting Author Steven Koller

Track Adult

Keywords

pancreaticopleural fistula

chronic pancreatitis

pleural effusion

pancreatic pseudocyst

empyema

pleural fluid amylase

pleural fluid lipase

ERCP

octreotide

thoracentesis

Pancreaticopleural Fistula

Pleural Effusion

Pleural Fluid

Amylase

Pancreatitis