CHRONIC PANCREATITIS RARE COMPLICATION, PANCREATIC-PLEURAL FISTULA &PLEURAL PSEUDOCYST: A CASE REPORT

Amal Salem 1 , Ahmed Azhari 1 , Amjad Banjar 2 and Maher Ghazzawy 3 . 1. Medical Intern, Umm Al-Qura University, Makkah, Saudi Arabia. 2. Radiology Resident, the Saudi Board of Radiology, Makkah, Saudi Arabia. 3. Radiologist, Al-Noor Specialist Hospital, Makkah, Saudi Arabia. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History


Introduction:-
Pancreatic pseudocysts often complicate chronic pancreatitis. Leakage of pancreatic enzymes triggers fistula formation due to erosion of the bowel wall into a hollow viscus, which communicates with other cavities. Fistula formation between a pancreatic pseudocyst and the pleura is rare and could present with a pleural effusionsuch effusions typically show high amylase content [J. L. Cameron.1978] because of direct drainage of pancreatic secretions into the pleural cavity secondary to acute/chronic inflammation and trauma/iatrogenic injury to the pancreatic duct. We describe a patient with chronic pancreatitis complicated by pancreatic-pleural fistula (PPF) formation with pleural effusion and pseudocyst.[Sommer CA. 2014] Case History:-A 16-year-old boy presented to the hospital with progressive shortness of breath and cough over 3 months, with diffuse abdominal pain radiating to his back and left shoulder. Eating exacerbated his pain, which was associated with nausea and vomiting. He reported positive history of weight loss and loss of appetite, but no fever, jaundice, itching, night sweats, melaena or hematemesis.
Upon admission, his temperature was 37.1 °C, blood pressure was 120/70, pulse rate was 120/min, respiratory rate was 22/min, and oxygen saturation was 95% on room air. Chest examination revealed left-sided decreased air entry with stony dullness to percussion and right-sided tracheal deviation.
A chest X-ray showed massive left-sided pleural effusion, as Figure 1.  is noted perivascularly in the upper mediastinum showing smooth peripheral enhancement. The medial aspect of the right lower lobe shows small ill-defined consolidation, likely secondary to compression of the displaced adjacent mediastinal structures. No other nodules, masses, cavitary lesions, or pleural effusion are noted.

Abdomen and pelvis:-
Multiple, variable-sized and shaped intra-ductal pancreatic calcifications are noted-the largest measuring 2 ×1.2 cm in the intra-ductal portion of the body. The pancreas is small in size. A tubular tract (likely fistula) is observed originating from the distal pancreatic body/tail, ascending toward the crus of the left hemidiaphragm. The adjacent major vascular structures are grossly intact, as Figure 2 .
The patient was administered broad-spectrum antibiotics, and analgesics and underwent left-sided thoracentesis with drainage of 1800 cm3 of pleural fluid, which showed an amylase level of 28,459 IU/L (reference range 30-100 IU/L).
On the second day of hospitalization, he underwent magnetic resonance cholangiopancreatography (MRCP) for diagnostic confirmation of the pancreatic fistula, and we observed atrophic pancreas with a dilated pancreatic duct and multiple pancreatic duct stones. A 1.6 cm defect noted in the distal body of the pancreas likely represented the site of leakage, as Figure 3 . The patient's symptoms improved post procedure, and he was discharged from the hospital on day 8 but was lost to follow-up.

Discussion:-
Acute and/or chronic pancreatitis is associated with the accumulation of enzyme-rich fluid, which after 6 weeks, gets encapsulated by granulation tissue and extracellular matrix to form pancreatic pseudocysts without an epithelial lining unlike true cysts. showed dyspnoea, cough and diffuse abdominal pain radiating to the back and left shoulder associated with nausea and vomiting.
Pancreatic pseudocysts occur secondary to leakage of enzymes that damage the pancreatic duct to form fluid collections that are typically confined to the lesser sac, although these can extend cranially or caudally along preferential drainage pathways, such as the lesser sac, the anterior/posterior para-renal space, the peri-splenic area, and the lower lobe of the liver. Several treatment strategies are used to manage PPF including medical treatment, drainage of the fluid collection, or endoscopic surgery, which shows lower morbidity rates than those noted with open surgery. [Lerch MM. 2009] Treatment is optimised based on symptom severity, anatomy of the fistulous tract, size of the fluid collection, and the available expertise. Our patient was treated medically with broad-spectrum antibiotics and analgesics, followed by thoracentesis for drainage of the fluid. An ERCP was performed to visualise the fistulous tract, and a 7 French stent was inserted.

Conclusion:-
Although pancreatic pseudocyst formation is a known complication of chronic pancreatitis, a PPF presenting with a pleural effusion is rare. An MRCP is the gold standard diagnostic test, and pleural fluid obtained via diagnostic thoracentesis reveals high amylase levels (>1000 U/L). The management strategy comprises initial medical treatment, followed by fluid drainage, and ERCP-guided stent placement into the fistulous tract. In refractory cases, endoscopic surgery is required.