CASE 12231 Published on 28.10.2014

CT and MRI\'s contribution in pancreatopleural fistula diagnosis

Section

Abdominal imaging

Case Type

Clinical Cases

Authors

Soares, José Tiago; Marques, Inês; Ressurreição, João; Batista, Lara; Portugal,Pedro

Centro Hosp. Vila Nova de Gaia, Radiology; Rua Conceicao Fernandes 4430 Vila Nova de Gaia, Portugal; Email:josetiagosoares@sapo.pt

Patient

46 years, male

Categories

Area of Interest Thorax ; Imaging Technique MR

Procedure Comparative studies, Cholangiography ; Special Focus Fistula ;

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Clinical History

A 43 year-old male, presented to our emergency department (ED) with sudden onset effort dyspnoea and no other associated symptoms. Physical examination revealed no signs of resting respiratory distress and auscultation showed diminished respiratory sounds on the left lung.

Imaging Findings

Chest X-Rays showed a left, large volume pleural effusion.

Thoracoabdominal CT 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 (fig.1-d). Although very discrete, one could visualize a thin fistulous tract communicating this collection with the left pleural cavity.(fig.1-a-d)

Drainage of the pleural fluid revealed a hematic exudate, with an amylase concentration of 5645 U/L.

MRCP (fig.2) confirmed the diagnosis of a pancreatopleural fistula (PPF), allowing a better depiction of the fistulous tract which originated in the body-tail transition, in a small pancreatic collection in continuity with the main pancreatic duct. The fistulous tract extended towards the chest, communicating with the left pleural space through the aortic hiatus.

Discussion

The diagnosis of a pancreatopleural fistula (PPF) is frequently delayed, as this condition is rare and frequently asymptomatic.[1] 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.[2]

PPFs are estimated to occur in around 0,4% of all the pancreatitis and in 4,5% of patients with a pancreatic pseudo cyst.[3] Diagnosed patients with PPFs are predominantly (83%) men, with chronic pancreatitis usually associated with long-term alcohol consumption.[4]

The most common symptoms are related to the pleural effusion and include dyspnea (65%), cough (29%) and chest pain (27%).[4] Abdominal pain has been reported in 23% of the cases.[4]

According to the literature, CT scan is the preferred imaging technique, allowing the identification of the fistulous tract in 33-47% of cases.[4-7]

Magnetic Resonance Cholangiopancreatography (MRCP) is also a method of choice for the diagnosis of PPF, with a sensitivity of 80% and a good alternative to CT. It is noninvasive and able to identify PPF even in the context of severe ductal stricture. [4-6, 8-10] 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.[6,11]

In the reported case, MRCP led to the confirmation of the fistulous tract and the identification of its origin on a ductal stenotic component near the pancreatic body-tail transition.

Endoscopic Retrograde Cholangiopancreatography (ERCP) is the second most efficient modality on PPF diagnosis, with a sensitivity of 46-78%.[4,5] Although this is an invasive method potentially associated with complications, ERCP is widely used when pancreatic ductal obstruction or main pancreatic duct rupture occur, allowing for simultaneous diagnosis and treatment.[4,5]

Medical conservative treatment of PPF consists on somatostatin analogs, parenteral nutrition and pleural fluid drainage.[1] Surgery is necessary whenever less invasive approaches fail. Every surgical approach requires a previous detailed imagiologic assessment of the pancreatic ducts and surrounding structures.[4-6]

After 5 weeks of conservative treatment, there was no significant regression of the pleural effusion, ERCP was performed with ductal decompression. All these measures were insuficient and surgical treatment was employed, with a body-tail pancreatectomy and Y-Roux pancreatojejunostomy.

Pancreatopleural fistulas must be taken into account in cases of large volume pleural effusion. Advanced imaging techniques, especially MRCP, allow for the direct visualization of fistulous tracts and for the establishment of the diagnosis and treatment planning.

Differential Diagnosis List

Pancreatopleural fistula

lung carcinoma

pneumonia

oesophageal perforation

acute pancreatitis

Final Diagnosis

Pancreatopleural fistula

References

[1] Kumar, A., et al. (2002) Sonographic demonstration of a pancreatopleural fistula. J Clin Ultrasound 30(8): p. 503-5. (PMID: 12242740)

[2] Wakefield, S., B. Tutty, and J. Britton (1996) Pancreaticopleural fistula: a rare complication of chronic pancreatitis. Postgrad Med J 72(844): p. 115-6 (PMID: 8871464)

[3] Olakowski, M., et al. (2009) Surgical management of pancreaticopleural fistulas. Acta Chir Belg 109(6): p. 735-40. (PMID: 20184058)

[4] Ali, T., et al (2009) Pancreaticopleural fistula. Pancreas 38(1): p. e26-31 (PMID: 19106743)

[5] King, J.C., et al. (2010) Pancreatic-pleural fistula is best managed by early operative intervention. Surgery 147(1): p. 154-9 (PMID: 19744435)

[6] Tajima, Y., et al (2006) Evaluation and management of thoracopancreatic fistula. Surgery 140(5): p. 773-8 (PMID: 17084720)

[7] Ito, H., et al. (2002) Two cases of thoracopancreatic fistula in alcoholic pancreatitis: clinical and CT findings. Radiat Med 20(4): p. 207-11 (PMID: 12296438)

[8] Tajima, Y., et al (2004) Demonstration of a pancreaticopleural fistula with magnetic resonance cholangiopancreatography. Am J Surg 187(6): p. 741-2 (PMID: 5191868)

[9] Materne, R., et al (2000) Pancreaticopleural fistula: diagnosis with magnetic resonance pancreatography. Chest 117(3): p. 912-4 (PMID: 10713030)

[10] Akahane, T., et al (2003) Pancreatic pleural effusion with a pancreaticopleural fistula diagnosed by magnetic resonance cholangiopancreatography and cured by somatostatin analogue treatment. Abdom Imaging. Abdom Imaging 28(1): p. 92-5 (PMID: 12483394)

[11] Galluzzo, A., et al (2008) A pancreatico-pleural fistula diagnosed with magnetic resonance cholangiopancreatography. JOP 9(5): p. 654-7 (PMID: 18762699)

Case information

URL:	https://www.eurorad.org/case/12231
DOI:	10.1594/EURORAD/CASE.12231
ISSN:	1563-4086

Figure 1

Series of CT and MRCP axial planes

a-d- Axial CT scan: large volume left pleural effusion; signs of chronic pancreatitis; pancreatopleural fistulous tract –dashed circles. e-h–MRCP: pancreatopleural fistulous tract communicating with the pleural space through the aortic hiatus–dashed circles

Figure 2

3D MRCP

MRCP - sinuous fistulous tract (arrows) communicating the pancreatic duct with the left pleural cavity, contributing to the large pleural effusion (*).