Pancreaticopleural Fistula Visualized by Computed

Takashi Fujiwara, Terumi Kamisawa, Junko Fujiwara, Yuyang Tu, Hitoshi Nakajima,
Naoto Egawa
Department of Internal Medicine, Tokyo Metropolitan Komagome Hospital. Tokyo, Japan
ABSTRACT
Context We report a case of a pancreatic-
opleural fistula which was clearly
demonstrated by computed tomography (CT)
scan following pancreatography and which
was successfully treated with endoscopic
nasopancreatic drainage combined with
octreotide.
Case report A 52-year-old male was
admitted to our hospital for additionally
evaluation of bilateral pleural effusion. The
pleural fluid amylase level was markedly
elevated. Endoscopic retrograde pancreat-
ography showed a cyst in the body of the
pancreas and extravasation of contrast
medium extending cranially from the cyst.
The disease was treated successfully with
endoscopic nasopancreatic drainage combined
with the administration of octreotide. A
pancreaticopleural fistulous route was clearly
demonstrated by CT scan following
pancreatography through the nasopancreatic
drainage tube.
Conclusions
A CT scan following
pancreatography was useful in demonstrating
a pancreaticopleural fistulous route.
INTRODUCTION
A pancreaticopleural fistula is a rare
complication of pancreatitis [1]. It can be
demonstrated by endoscopic retrograde
cholangiopancreatography (ERCP) [2, 3, 4] or
magnetic resonance cholangiopancreat-
ography (MRCP) [5] , but these imaging
methods sometimes fail to demonstrate a
fistulous tract. A computed tomography (CT)
scan offers an effective diagnostic method for
the anatomic evaluation of the intrathoracic
route of a pancreatic fistula [6, 7]. The
successful treatment of pancreaticopleural
fistula using endoscopic therapeutic options,
including transpapillary stent placement or
transpapillary nasopancreatic drainage, has
been reported [8, 9, 10]. We present a case in
which a CT scan performed following
pancreatography clearly demonstrated a
pancreaticopleural fistulous route and the
anatomical relationship with other organs; the
disease was successfully treated with
endoscopic nasopancreatic drainage combined
with the administration of octreotide.
CASE REPORT
A 52-year-old male visited his family doctor
complaining of fever and back pain. As a
chest radiography showed bilateral pleural
effusion, he was referred to our hospital
(Figure 1). On admission, he was pyrexial,
dyspnoetic and tachypnoetic, with dullness
and decreased air entry at the base of both
lungs. He had drunk a half bottle of whisky
daily for 20 years, but he had experienced no
attacks of pancreatitis. The laboratory data
were the following: white blood cell count,

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JOP. Journal of the Pancreas - http://www.joplink.net - Vol. 7, No. 2 - March 2006. [ISSN 1590-8577]
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9,300 µL
-1
(reference range: 3,700-8,300 µL
-
1
), C-reactive protein 12.9 mg/dL (reference
range: 0-0.3 mg/dL), and serum amylase
1,491 IU/L (reference range: 40-155 IU/L).
An abdominal CT scan showed a 2 cm cystic
lesion in the pancreatic body and dilatation of
the main pancreatic duct of the tail of the
pancreas. MRCP demonstrated an irregular
cystic lesion in the body of the pancreas.
ERCP showed mild stenosis of the main
pancreatic duct and a cyst in the body of the
pancreas (Figure 2a). Furthermore, extra-
vasation of contrast medium extending
cranially from the cyst was demonstrated
(Figure 2b), but it was unclear whether the
leakage reached the pleural cavity. The
pleural fluid amylase level was markedly
elevated (right 42,740 IU/L, and left 118,020
IU/L). He was diagnosed as having a
pancreaticopleural fistula associated with
acute pancreatitis. Although the patient was
treated conservatively, with thoracentesis,
fasting, total parenteral nutrition and
administration of gabexate mesilate for 4
weeks, and amylase-rich fluid was drained
continuously through the chest tube.
Therefore, a 5-Fr transpapillary nasopancreat-
ic drainage tube with side holes (Wilson Cook
Medical Inc., Winston-Salem, NC, USA) was
inserted endoscopically into the main
pancreatic duct so that it bridged the leak. On
CT performed following pancreatography
through the nasopancreatic drainage tube, a
pancreaticopleural fistulous route was
demonstrated to originate from a cyst in the
pancreatic body, penetrate along the
esophagus into the mediastinum and extend to
the bilateral pleural cavities (Figure 3a-d).
Octreotide (300 µg/day) was also
administered subcutaneously. After 3 days of
drainage, pleural effusion stopped. ERCP
Figure 1. Chest radiography on admission showing
bilateral pleural effusion.
Figure 2. Endoscopic retrograde cholangiopancreat-
ography showing stenosis of the main pancreatic duct
and a cyst in the body of the pancreas (a). Furthermore,
extravasation (arrow) of contrast medium extending
cranially from the cyst was demonstrated (b).

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232
after treatment showed closure of the
pancreaticopleural fistula. During a 2-year
follow-up period, recurrence of pancreatic
pleural effusion was not detected on chest
radiography.
DISCUSSION
Pancreatic effusion due to a pancreatic-
opleural fistula is a rare complication of
pancreatitis [1]. A pancreaticopleural fistula
results from the posterior disruption of the
pancreatic duct or a pancreatic cyst into the
retroperitoneal space, leading to the formation
of a fistulous tract between the pancreas and
the pleural cavity through the aortic or
esophageal hiatus. A markedly elevated
pleural fluid amylase level is the most
important laboratory finding [5]. A
pancreaticopleural
fistula
can
be
demonstrated by ERCP or MRCP, but the
entire anatomy of the fistula will not always
be delineated [2, 3, 4]. A CT scan is also
useful in diagnosing the anatomic evaluation
of the intrathoracic route of a pancreatic
fistula [6, 7]. In the present case, a CT scan
performed following pancreatography
clarified the anatomical relationship of the
fistula with other organs as well as with the
pancreas.
Most patients with pancreatic pleural effusion
are initially treated conservatively with
thoracentesis, fasting and drugs which reduce
pancreatic exocrine secretion. The response
rate to the conservative treatment has been
reported to be 40-50% [11]. If a complete
cure is not obtained after several weeks,
surgical intervention is indicated. Recently,
endoscopic therapeutic options, including
transpapillary stent placement or transpapil-
lary nasopancreatic drainage, have been
successfully used in patients with a
pancreaticopleural fistula [8, 9, 10].
Placement of a transpapillary nasopancreatic
drain can facilitate the healing of ductal
ruptures by partially occluding the leaking
duct or by traversing the pancreatic sphincter
converting the high-pressure pancreatic duct
system to a low-pressure system with
preferential flow through the drainage tube
[12]. Octreotide, a long-acting somatostatin
analogue, inhibits pancreatic exocrine
secretion [13] and its use is recommended for
the treatment of high-output pancreatic
fistulas [14]. In the present case, endoscopic
nasopancreatic drainage combined with the
administration of octreotide was very useful
in treating the pancreaticopleural fistula.
In conclusion, we report a case of bilateral
pancreatic pleural effusion with a
pancreaticopleural fistula caused by
pancreatitis. A pancreaticopleural fistulous
route was clearly demonstrated by a CT scan
following pancreatography, and the disease
was treated successfully with endoscopic
nasopancreatic drainage combined with the
administration of octreotide.
Received January 17
th
, 2006 - Accepted
February 2
nd
, 2006
Keywords
Cholangiopancreatography,
Endoscopic Retrograde; Pancreas; Pancreatic
Fistula; Pancreatitis; Respiratory Tract
Fistula; Tomography, X-Ray Computed
Abbreviations ERCP: endoscopic retrograde
cholangiopancreatography
Figure 3. On a CT scan performed following
pancreatography through the nasopancreatic drainage
tube, a pancreaticopleural fistulous route (arrows) was
demonstrated to originate from a cyst in the pancreatic
body (a), extend cranially (b), penetrate along the
esophagus into the mediastinum (c) and extend to the
bilateral pleural cavities (d).

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JOP. J Pancreas (Online) 2006; 7(2):230-233.
JOP. Journal of the Pancreas - http://www.joplink.net - Vol. 7, No. 2 - March 2006. [ISSN 1590-8577]
233
Correspondence
Terumi Kamisawa
Department of Internal Medicine
Tokyo Metropolitan Komagome Hospital
3-18-22 Honkomagome, Bunkyo-ku
Tokyo 113-8677
Japan
Phone: +81-3.3823.2101
Fax: +81-3.3824.1552
E-mail: kamisawa@cick.jp
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