Pancreatopleural fistula contributing to a large volume recurrent pleural effusion
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"apellidos" => "Chen" ] 4 => array:2 [ "Iniciales" => "H." "apellidos" => "Gao" ] 5 => array:2 [ "Iniciales" => "J." "apellidos" => "Zuo" ] 6 => array:2 [ "Iniciales" => "Y." "apellidos" => "Yang" ] 7 => array:2 [ "Iniciales" => "L." "apellidos" => "Tang" ] 8 => array:2 [ "Iniciales" => "H." "apellidos" => "Cao" ] 9 => array:2 [ "Iniciales" => "Y." "apellidos" => "Chen" ] 10 => array:2 [ "Iniciales" => "L." "apellidos" => "Li" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X0873215915188440?idApp=UINPBA00004E" "url" => "/08732159/0000002100000003/v0_201604141146/X0873215915188440/v0_201604141146/en/main.assets" ] "en" => array:11 [ "idiomaDefecto" => true "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 [ "Iniciales" => "J.T." "apellidos" => "Soares" "email" => array:1 [ 0 => "josetiagosoares@sapo.pt" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor1" ] ] ] 1 => array:3 [ "Iniciales" => "J." "apellidos" => "Ressurreição" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 2 => array:3 [ "Iniciales" => "I." "apellidos" => "Marques" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 3 => array:3 [ "Iniciales" => "L." "apellidos" => "Batista" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 4 => array:3 [ "Iniciales" => "T." 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"apellidos" => "Mendes" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] ] "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" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] 1 => array:3 [ "entidad" => "Serviço de Cirurgia Geral do Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor1" "etiqueta" => "<span class="elsevierStyleSup">*</span>" "correspondencia" => "Corresponding author. josetiagosoares@sapo.pt" ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig1" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "descripcion" => array:1 [ "en" => "(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." ] ] ] "textoCompleto" => "<p class="elsevierStylePara">The diagnosis of a pancreatopleural fistula (PPF) is frequently delayed, because this is a rare condition and is often asymptomatic.<a href="#bib8" class="elsevierStyleCrossRefs"><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 href="#bib9" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">2</span></a></p><p class="elsevierStylePara">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 class="elsevierStylePara">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 href="#f0005" class="elsevierStyleCrossRefs">Figure 1</a>d). Although very discrete, one could hardly visualize a thin fistulous tract communicating this collection with the left pleural cavity (<a href="#f0005" class="elsevierStyleCrossRefs">Figure 1</a>a–d).</p><a name="f0005" class="elsevierStyleCrossRefs"></a><p class="elsevierStylePara"><img src="320v21n03-" alt="(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."></img></p><p class="elsevierStylePara">Figure 1. (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><p class="elsevierStylePara">Drainage of the pleural fluid revealed a hematic exudate, with an amylase concentration of 5645 U/L.</p><p class="elsevierStylePara">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 class="elsevierStylePara">PPFs are estimated to occur in around 0.4% of all the pancreatitis and in 4.5% of patients with a pancreatic pseudocyst.<a href="#bib15" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">3</span></a></p><p class="elsevierStylePara">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 href="#bib11" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">4</span></a></p><p class="elsevierStylePara">Patients with PPFs are predominantly (83%) men, on their fourth decade of life, with chronic pancreatitis usually associated with long-term alcohol consumption.<a href="#bib12" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">5</span></a></p><p class="elsevierStylePara">The most common symptoms are related to the pleural effusion and include dyspnea (65%), cough (29%) and chest pain (27%).<a href="#bib12" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">5</span></a> Abdominal pain has been reported in 23% of the cases.<a href="#bib12" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">5</span></a></p><p class="elsevierStylePara">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 href="#bib11" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">4</span></a><span class="elsevierStyleSup">, </span><a href="#bib12" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">5</span></a><span class="elsevierStyleSup">, </span><a href="#bib13" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">6</span></a></p><p class="elsevierStylePara">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 href="#bib11" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">4</span></a><span class="elsevierStyleSup">, </span><a href="#bib12" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">5</span></a><span class="elsevierStyleSup">, </span><a href="#bib14" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">7</span></a></p><p class="elsevierStylePara">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 href="#bib11" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">4</span></a><span class="elsevierStyleSup">, </span><a href="#bib14" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">7</span></a></p><p class="elsevierStylePara">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 class="elsevierStylePara">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 class="elsevierStylePara">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 class="elsevierStylePara">An endoscopic retrograde colangiopancreatography (ERCP) was performed, with Wirsung duct sphincterotomy for decompression.</p><p class="elsevierStylePara">Medical conservative treatment of PPF is usually maintained for 2–3 weeks.<a href="#bib8" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">1</span></a> In this case, given the immunodepressed state of the patient, surgery was postponed.</p><p class="elsevierStylePara">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 class="elsevierStylePara">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><a name="sec0005" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p class="elsevierStylePara">The authors have no conflicts of interest to declare.</p><p class="elsevierStylePara">Acknowledgment</p><p class="elsevierStylePara">A special word of acknowledgment to Dr. Ana Sofia Figueiredo for her precious help in the elaboration of this paper.</p><p class="elsevierStylePara">Corresponding author. josetiagosoares@sapo.pt</p>" "pdfFichero" => "320v21n03a90418845pdf001.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig1" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "descripcion" => array:1 [ "en" => "(a)¿(d) Axial thoracoabdominal CT scan: large volume left pleural effusion; signs of chronic pancreatitis-diffuse pancreatic calcifications, (d) pancreatopleural fistulous tract ¿ dashed circles. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 11 | 6 | 17 |
| 2024 October | 50 | 28 | 78 |
| 2024 September | 45 | 19 | 64 |
| 2024 August | 65 | 32 | 97 |
| 2024 July | 62 | 37 | 99 |
| 2024 June | 67 | 23 | 90 |
| 2024 May | 40 | 30 | 70 |
| 2024 April | 66 | 28 | 94 |
| 2024 March | 46 | 23 | 69 |
| 2024 February | 51 | 29 | 80 |
| 2024 January | 39 | 29 | 68 |
| 2023 December | 31 | 31 | 62 |
| 2023 November | 40 | 32 | 72 |
| 2023 October | 33 | 37 | 70 |
| 2023 September | 36 | 32 | 68 |
| 2023 August | 42 | 16 | 58 |
| 2023 July | 35 | 30 | 65 |
| 2023 June | 31 | 23 | 54 |
| 2023 May | 47 | 25 | 72 |
| 2023 April | 33 | 11 | 44 |
| 2023 March | 61 | 20 | 81 |
| 2023 February | 47 | 24 | 71 |
| 2023 January | 35 | 14 | 49 |
| 2022 December | 46 | 18 | 64 |
| 2022 November | 73 | 44 | 117 |
| 2022 October | 74 | 33 | 107 |
| 2022 September | 32 | 35 | 67 |
| 2022 August | 49 | 45 | 94 |
| 2022 July | 54 | 53 | 107 |
| 2022 June | 50 | 31 | 81 |
| 2022 May | 75 | 38 | 113 |
| 2022 April | 41 | 36 | 77 |
| 2022 March | 47 | 38 | 85 |
| 2022 February | 37 | 32 | 69 |
| 2022 January | 34 | 31 | 65 |
| 2021 December | 38 | 36 | 74 |
| 2021 November | 41 | 43 | 84 |
| 2021 October | 40 | 40 | 80 |
| 2021 September | 28 | 26 | 54 |
| 2021 August | 37 | 22 | 59 |
| 2021 July | 37 | 13 | 50 |
| 2021 June | 25 | 24 | 49 |
| 2021 May | 42 | 29 | 71 |
| 2021 April | 114 | 75 | 189 |
| 2021 March | 68 | 24 | 92 |
| 2021 February | 65 | 18 | 83 |
| 2021 January | 46 | 12 | 58 |
| 2020 December | 50 | 8 | 58 |
| 2020 November | 52 | 11 | 63 |
| 2020 October | 35 | 19 | 54 |
| 2020 September | 62 | 15 | 77 |
| 2020 August | 72 | 24 | 96 |
| 2020 July | 89 | 22 | 111 |
| 2020 June | 87 | 18 | 105 |
| 2020 May | 76 | 23 | 99 |
| 2020 April | 82 | 8 | 90 |
| 2020 March | 75 | 11 | 86 |
| 2020 February | 57 | 22 | 79 |
| 2020 January | 71 | 19 | 90 |
| 2019 December | 58 | 20 | 78 |
| 2019 November | 60 | 22 | 82 |
| 2019 October | 770 | 20 | 790 |
| 2019 September | 65 | 22 | 87 |
| 2019 August | 143 | 12 | 155 |
| 2019 July | 141 | 18 | 159 |
| 2019 June | 148 | 6 | 154 |
| 2019 May | 143 | 9 | 152 |
| 2019 April | 126 | 24 | 150 |
| 2019 March | 197 | 9 | 206 |
| 2019 February | 155 | 16 | 171 |
| 2019 January | 183 | 23 | 206 |
| 2018 December | 88 | 7 | 95 |
| 2018 November | 29 | 0 | 29 |
| 2018 October | 53 | 15 | 68 |
| 2018 September | 22 | 10 | 32 |
| 2018 August | 40 | 25 | 65 |
| 2018 July | 29 | 15 | 44 |
| 2018 June | 37 | 18 | 55 |
| 2018 May | 46 | 24 | 70 |
| 2018 April | 76 | 36 | 112 |
| 2018 March | 60 | 11 | 71 |
| 2018 February | 38 | 10 | 48 |
| 2018 January | 10 | 13 | 23 |
| 2017 December | 53 | 19 | 72 |
| 2017 November | 17 | 15 | 32 |
| 2017 October | 13 | 5 | 18 |
| 2017 September | 24 | 20 | 44 |
| 2017 August | 33 | 14 | 47 |
| 2017 July | 19 | 11 | 30 |
| 2017 June | 24 | 16 | 40 |
| 2017 May | 28 | 20 | 48 |
| 2017 April | 11 | 4 | 15 |
| 2017 March | 17 | 9 | 26 |
| 2017 February | 7 | 7 | 14 |
| 2017 January | 8 | 4 | 12 |
| 2016 December | 13 | 10 | 23 |
| 2016 November | 5 | 6 | 11 |
| 2016 October | 3 | 2 | 5 |
| 2016 September | 3 | 1 | 4 |
| 2016 August | 8 | 3 | 11 |
| 2016 July | 6 | 10 | 16 |
| 2016 April | 15 | 1 | 16 |
| 2016 March | 26 | 11 | 37 |
| 2016 February | 34 | 23 | 57 |
| 2016 January | 23 | 16 | 39 |
| 2015 December | 28 | 17 | 45 |
| 2015 November | 17 | 12 | 29 |
| 2015 October | 21 | 23 | 44 |
| 2015 September | 45 | 34 | 79 |
| 2015 August | 46 | 36 | 82 |
| 2015 July | 38 | 21 | 59 |
| 2015 June | 48 | 33 | 81 |
| 2015 May | 109 | 87 | 196 |
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