Letter to the Editor
Pancreatopleural fistula contributing to a large volume recurrent pleural effusion
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(A) Chest CT images with cystic and varicose bronchiectasis, as well as peribronchovascular reticulation. (B) Chest CT images confirming the presence of parenchymal densifications, bilateral ground glass opacities and predominance of a mosaic pattern. (C) Photomicrograph illustrating the presence of agglomerates of collagen surrounding the bronchovascular axes with widespread alveolar distension, resulting in concentric narrowing and obliteration. H stain, 100× original magnification. (D) Photomicrograph illustrating the presence of fibroblast proliferation associated with collagen deposition, as well as alveolar and septal rupture and centrilobular emphysema. These features result in constriction of the airway lumen, which is compatible with the definitive diagnosis of constrictive bronchiolitis. H&E stain, 100× original magnification.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "D. Madama, A. Silva, S. Freitas, F. 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"apellidos" => "Gamboa" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S217351151500041X?idApp=UINPBA00004E" "url" => "/21735115/0000002100000003/v2_201505070217/S217351151500041X/v2_201505070217/en/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S2173511515000159" "issn" => "21735115" "doi" => "10.1016/j.rppnen.2014.11.003" "estado" => "S300" "fechaPublicacion" => "2015-05-01" "aid" => "1019" "copyright" => "Sociedade Portuguesa de Pneumologia" "documento" => "article" "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "sco" "cita" => "Rev Port Pneumol. 2015;21:157-62" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 1775 "formatos" => array:3 [ "EPUB" => 239 "HTML" => 1012 "PDF" => 524 ] ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Immune influence of pregnancy on human H7N9 infection: a case report" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "157" "paginaFinal" => "162" ] ] "contieneResumen" => array:1 [ "en" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2407 "Ancho" => 3168 "Tamanyo" => 320674 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Alterations in various cell counts at different time points since hospital admission between the pregnant and non-pregnant H7N9 patients. (a) White blood cell counts; (b) neutrophil counts; (c) lymphocytes counts; (d) monocyte counts.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "G. Cui, H. Diao, Y. Wei, J. Chen, H. Gao, J. Zuo, Y. Yang, L. Tang, H. Cao, Y. Chen, L. Li" "autores" => array:11 [ 0 => array:2 [ "nombre" => "G." "apellidos" => "Cui" ] 1 => array:2 [ "nombre" => "H." "apellidos" => "Diao" ] 2 => array:2 [ "nombre" => "Y." "apellidos" => "Wei" ] 3 => array:2 [ "nombre" => "J." "apellidos" => "Chen" ] 4 => array:2 [ "nombre" => "H." "apellidos" => "Gao" ] 5 => array:2 [ "nombre" => "J." "apellidos" => "Zuo" ] 6 => array:2 [ "nombre" => "Y." "apellidos" => "Yang" ] 7 => array:2 [ "nombre" => "L." "apellidos" => "Tang" ] 8 => array:2 [ "nombre" => "H." "apellidos" => "Cao" ] 9 => array:2 [ "nombre" => "Y." "apellidos" => "Chen" ] 10 => array:2 [ "nombre" => "L." "apellidos" => "Li" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173511515000159?idApp=UINPBA00004E" "url" => "/21735115/0000002100000003/v2_201505070217/S2173511515000159/v2_201505070217/en/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Pancreatopleural fistula contributing to a large volume recurrent pleural effusion" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "163" "paginaFinal" => "164" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "J.T. Soares, J. Ressurreição, I. Marques, L. Batista, T. Pereira, M. Mendes" "autores" => array:6 [ 0 => array:4 [ "nombre" => "J.T." "apellidos" => "Soares" "email" => array:1 [ 0 => "josetiagosoares@sapo.pt" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "J." "apellidos" => "Ressurreição" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "I." "apellidos" => "Marques" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "L." "apellidos" => "Batista" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "T." "apellidos" => "Pereira" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "M." "apellidos" => "Mendes" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Serviço de Imagiologia do Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Serviço de Cirurgia Geral do Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1524 "Ancho" => 3249 "Tamanyo" => 453702 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(a)–(d) Axial thoracoabdominal CT scan: large volume left pleural effusion; signs of chronic pancreatitis-diffuse pancreatic calcifications, (d) pancreatopleural fistulous tract – dashed circles. (e)–(h) MRCP axial planes: allow for a better depiction of the fistulous tract communicating with the pleural space through the aortic hiatus – dashed circles.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The diagnosis of a pancreatopleural fistula (PPF) is frequently delayed, because this is a rare condition and is often asymptomatic.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> The presence of a large volume pleural effusion with high protein and pancreatic enzymes content, that recurs after chest tube drainage, may be its only manifestation.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">A 43-year-old male, HIV positive on combined antiretroviral therapy, presented to our emergency department (ED) with sudden effort dyspnea and no other associated symptoms. Physical examination revealed diminished respiratory sounds on the left lung. Chest X-rays showed a left, large volume pleural effusion.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Thoracoabdominal CT scan demonstrated a large volume left pleural effusion and signs of chronic pancreatitis (multiple diffuse calcifications, Wirsung dilatation) and a small pancreatic fluid collection adjacent to the Wirsung in the body–tail transition (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>d). Although very discrete, one could hardly visualize a thin fistulous tract communicating this collection with the left pleural cavity (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>a–d).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Drainage of the pleural fluid revealed a hematic exudate, with an amylase concentration of 5645<span class="elsevierStyleHsp" style=""></span>U/L.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Magnetic resonance cholangiopancreatography (MRCP), performed 5 days after admission, confirmed the diagnosis, allowing a better depiction of the fistulous tract, which was originated in the body–tail transition, in a small pancreatic collection in continuity with the main pancreatic duct. The fistulous tract extended toward the chest, communicating with the left pleural space through the aortic hiatus.</p><p id="par0030" class="elsevierStylePara elsevierViewall">PPFs are estimated to occur in around 0.4% of all the pancreatitis and in 4.5% of patients with a pancreatic pseudocyst.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">3</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Some authors suggest that the number of diagnosed or reported cases is underestimated and will tend to increase with progressive improvement of imaging techniques.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Patients with PPFs are predominantly (83%) men, on their fourth decade of life, with chronic pancreatitis usually associated with long-term alcohol consumption.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The most common symptoms are related to the pleural effusion and include dyspnea (65%), cough (29%) and chest pain (27%).<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> Abdominal pain has been reported in 23% of the cases.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">According to the literature, CT scan is the preferred imaging technique, allowing for the identification of the fistulous tract in 33–47% of cases.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">4–6</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">MRCP is also a method of choice for the diagnosis of PPF, with a sensitivity of 80% and a good alternative to CT. It has the advantage of being noninvasive and able to identify PPF even in the context of severe pancreatic duct stricture.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">4,5,7</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">It allows the recognition of ductal anatomy and pathologic changes of the surrounding structures, yielding important information for a better understanding of local anatomy and treatment planning.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">4,7</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">In the reported case, MRCP led, in fact, to the confirmation of the fistulous tract suspected in CT and the identification of its origin on a ductal stenotic component near the pancreatic body–tail transition.</p><p id="par0070" class="elsevierStylePara elsevierViewall">In this case, treatment consisted of several thoracentesis for pleural fluid evacuation and subsequent chest drain placement due to pleural effusion persistence. Somatostatin analogs and parenteral nutrition were also part of the treatment strategy.</p><p id="par0075" class="elsevierStylePara elsevierViewall">During the first week of treatment there was significant worsening of dyspnea, and an increase of the pleural effusion on X-ray. A new CT scan showed marked enlargement of the pleural effusion, with collapse of both left lung lobes and right deviation of the mediastinum.</p><p id="par0080" class="elsevierStylePara elsevierViewall">An endoscopic retrograde colangiopancreatography (ERCP) was performed, with Wirsung duct sphincterotomy for decompression.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Medical conservative treatment of PPF is usually maintained for 2–3 weeks.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> In this case, given the immunodepressed state of the patient, surgery was postponed.</p><p id="par0090" class="elsevierStylePara elsevierViewall">After 5 weeks of conservative treatment, there was no significant regression of the pleural effusion and a purulent fluid through the thoracic drain was observed. Surgical treatment was then employed, with a body–tail pancreatectomy and Y-Roux pancreatojejunostomy. After surgery the pleural effusion improved significantly and 10 days later the patient was discharged with no dyspnea, pain or other symptoms.</p><p id="par0095" class="elsevierStylePara elsevierViewall">In conclusion, pancreatopleural fistulas must be taken into account in cases of large volume pleural effusion in patients with a history of pancreatitis or pancreatic surgery. Advanced imaging techniques, like CT and especially MRCP, allows for the direct visualization of fistulous tracts and for the establishment of the diagnosis, yielding important information for a better understanding of local anatomy and treatment planning.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:2 [ "identificador" => "xack159840" "titulo" => "Acknowledgment" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1524 "Ancho" => 3249 "Tamanyo" => 453702 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(a)–(d) Axial thoracoabdominal CT scan: large volume left pleural effusion; signs of chronic pancreatitis-diffuse pancreatic calcifications, (d) pancreatopleural fistulous tract – dashed circles. (e)–(h) MRCP axial planes: allow for a better depiction of the fistulous tract communicating with the pleural space through the aortic hiatus – dashed circles.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sonographic demonstration of a pancreatopleural fistula" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A. Kumar" 1 => "L. Upreti" 2 => "S.K. Bhargava" 3 => "S. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 7 | 13 |
| 2024 October | 28 | 34 | 62 |
| 2024 September | 45 | 19 | 64 |
| 2024 August | 53 | 33 | 86 |
| 2024 July | 35 | 30 | 65 |
| 2024 June | 28 | 19 | 47 |
| 2024 May | 46 | 28 | 74 |
| 2024 April | 31 | 37 | 68 |
| 2024 March | 22 | 24 | 46 |
| 2024 February | 36 | 26 | 62 |
| 2024 January | 19 | 19 | 38 |
| 2023 December | 20 | 31 | 51 |
| 2023 November | 18 | 31 | 49 |
| 2023 October | 20 | 39 | 59 |
| 2023 September | 22 | 27 | 49 |
| 2023 August | 18 | 16 | 34 |
| 2023 July | 19 | 28 | 47 |
| 2023 June | 27 | 27 | 54 |
| 2023 May | 27 | 24 | 51 |
| 2023 April | 16 | 7 | 23 |
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