A Pancreatico-Pleural Fistula Diagnosed

Alessandra Galluzzo
1
, Elsa Iannicelli
1
, Massimo Marignani
2
,
Gianfranco Delle Fave
2, Vincenzo David1
1
Department of Radiology, S. Andrea Hospital, and
2
Department of Digestive and Liver Diseases;
Second School of Medicine, University “La Sapienza”. Rome, Italy
INTRODUCTION
Pancreatico-pleural fistula (PPF) represents a
rare complication of chronic pancreatitis,
especially in patients with an alcohol abuse
history. It results from the traumatic or
inflammatory disruption of the main
pancreatic duct or its side branches, leading to
the formation of a fistulous tract between the
pancreas and the pleural cavity through the
esophageal or aortic hiatus of the diaphragm
[1, 2]. We report a case of recurrent chronic
alcohol-related pancreatitis evolving into a
PPF in a young man who underwent magnetic
resonance cholangiopancreatography (MRCP).
CASE REPORT
A 29-year-old man, with increasing dyspnea,
mild abdominal epigastric discomfort,
anorexia and an indefinite weight loss in the
two months prior to hospitalization, was
admitted to our hospital. Past medical history
was relevant for chronic alcoholic
pancreatitis, first diagnosed two years before
the present admission.
Physical examination was suggestive of a
notable pleural effusion in the left pleural
cavity and only mild pain was elicited on
deep palpation of the epigastric region.
Laboratory data were as follows: serum
amylase 323 U/L (reference range: 8-53 U/L),
lipase 516 U/L (reference range: 8-78 U/L)
and calcium 7.9 mg/dL (reference range: 9-
10.5 mg/dL). No biochemical signs of
cholestasis or hepatocellular damage were
found.
The pleural effusion in the left pleural cavity
was confirmed by chest X-ray. Abdominal
ultrasound showed a moderately enlarged
pancreas and a round fluid collection with a
slightly thickened wall, 2 cm in size, located
in the pancreatic body. A small amount of
fluid was also noted in the omental bursa.
With the clinical suspicion of a PPF, further
evaluation by magnetic resonance (MR) and
MR-cholangiopancreatography (MRCP) was
requested.
Abdominal MRCP was performed by a 1.5 T
unit (Sonata Symphony Siemens, Erlangen,
Germany) with a phased-array body coil. We
used heavily T2-weighted sequences: a half-
Fourier single-shot turbo spin-echo (HASTE)
2D breath-hold (relaxation time 1,100 ms;
time of echo 87 ms; slice thickness 4 mm;
acquisition time 25 sec) and a turbo spin-echo
(TSE) 3D respiratory gated (relaxation time
1,820 ms; time of echo 401 ms; thickness 4
mm; acquisition time 150) with multiplanar
projection reconstruction (MPR) and multiple
intensity projection (MIP). Axial scans of the
upper abdomen with gradient echo fast low-
angle shot (GRE FLASH) 2D T1 weighted
and TSE T2-weighted sequences were also
obtained.
The TSE T2-weighted MR image showed a
moderately enlarged pancreatic body with

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JOP. J Pancreas (Online) 2008; 9(5):654-657.
JOP. Journal of the Pancreas - http://www.joplink.net - Vol. 9, No. 5 - September 2008. [ISSN 1590-8577]
655
irregular contours and diffusely non-
homogeneous signal intensity as well as a
pancreatic body pseudocyst (black arrows)
and main pancreatic ducct dilatation (grey
arrows) (Image 1). The coronal scan HASTE
2D T2-weighted scan demonstrated a part of
the proximal portion of the fistula (white
arrow); an irregular dilatation of the main
pancreatic duct side branches (black arrows)
as well as pleural effusion in the left pleural
cavity was also evident (asterisk) (Image 2).
A PPF (Image 3, arrows), clearly
demonstrated on the 3D MRCP sequence,
appears on two different oblique MIP images
as a high-signal intensity narrow structure
arising from the pancreatic body pseudocyst
(p) towards the left pleural cavity (asterisk).
The diagnosis of PPF was confirmed by
pleural fluid analysis, obtained by
thoracentesis (amylase 7,137 U/L, lipase
27,000 U/L). Medical treatment was started
with total parenteral nutrition (TPN) and the
administration of large spectrum antibiotics,
pancreatic enzymes, proton pump inhibitors
and octeotride (500 µg bid i.m.). The patient
was discharged, without dyspnea or
abdominal symptoms, on medical therapy and
TPN, in an improved general condition.
One month later, the fistulous tract was still
present on MR and MRCP with a reduction of
the omental bursa fluid collection and no
further signs of pleural effusion.
Unfortunately, the patient refused any other
additional follow-up.
Image 1.
Image 2.
Image 3.

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JOP. J Pancreas (Online) 2008; 9(5):654-657.
JOP. Journal of the Pancreas - http://www.joplink.net - Vol. 9, No. 5 - September 2008. [ISSN 1590-8577]
656
DISCUSSION
In this report, we describe the case of a PPF
with pleural effusion, a rare complication of
chronic alcoholic pancreatitis, with a reported
incidence in alcoholic patients of 0.4-
4.5%/year [3]. In the literature, some
examples of PPF have been studied with CT
[3, 4, 5] but only a few cases evaluated with
MRI [6, 7, 8, 9, 10] have been described. In
this clinical setting, the pathological process
develops as a leak from an incompletely
formed or ruptured pseudocyst. The fluid may
track to the peritoneal cavity (pancreatic
ascites) or into the pleural space through the
path of least resistance. In the case of a PPF,
the posterior rupture of a pancreatic
pseudocyst produces an initial collection of
pancreatic secretions in the omental bursa; it
then reaches the pleural space via the retro
peritoneum, usually through the esophageal or
aortic hiatus. In our case, the fistulous tract
arose from the pseudocyst of the pancreatic
body.
The demonstration of PPF by conventional
endoscopic and radiological techniques is
difficult. PPF has been mainly investigated by
endoscopic retrograde cholangiopancreatography
(ERCP). MRCP has the advantage of
obtaining rapid and accurate imaging of the
biliary tree and pancreatic ducts, without any
intravenous contrast agent administration
[10]. It can recognize and track the fistula all
the way to the pleural cavity, with an accurate
definition of its relationship with the
surrounding structures. Therefore, since
ERCP is a costly and invasive procedure, with
a small but significant complication rate (i.e.,
acute pancreatitis, bleeding, sepsis), we
believe that MR and MRCP should be the
diagnostic techniques of first choice when a
PPF is suspected. The use of ERCP should be
suggested when a therapeutic approach is
necessary (endoscopic pancreatic endo-
prosthesis placement) or in case of uncertain
MR findings.
In conclusion, MRCP can be considered a
relevant diagnostic tool in the evaluation of
chronic pancreatitis and its complications,
such as PPF. The integration of the
information provided by MR and MRCP
allows the more complete study of the
pancreatic
morphology
and
tissue
components, the detection of PPFs, thus
avoiding contrast medium administration and
ERCP related-risks, and the definition of the
most appropriate therapeutic plans.
Received April 8
th
, 2008 - Accepted June
23
rd
, 2008
Keywords
Pancreatic
Pseudocyst;
Pancreatitis, Alcoholic; Pleural Effusion
Abbreviations HASTE: half-Fourier single-
shot turbo spin-echo; MIP: multiple intensity
projection; MPR: multiplanar projection
reconstruction; PPF: pancreatico-pleural
fistula; TSE: turbo spin-echo
Conflict of interest No conflicts of interest
Correspondence
Alessandra Galluzzo
S. Andrea Hospital
Department of Radiology
II School of Medicine
University La Sapienza
Via di Grottarossa 1024
00100 Rome
Italy
Phone: +39-6.3377.5229
E-mail: alessandragalluzzo@libero.it
Document URL: http://www.joplink.net/prev/200809/09.html
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