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McGraw Hill. Download citation file: RIS Zotero. Four months after this event, the patient presented with abdominal pain secondary to partial obstruction of the pancreatic stent. This was exchanged with a 7 Fr by 7 cm plastic stent without complications. Follow-up examination at 2 weeks, and 4, 6, and18 months revealed no evidence of recurrent pleural effusion Figure 4.
Chest X-ray follow-up at: A 2 weeks, B 4 months, C 6 months, and D 18 months shows resolution of the pleural effusion. We present the case of a patient with a PPF to highlight the potential role of endoscopic management of this entity.
Diagnosis is usually delayed due to the absence of abdominal symptoms, as patients usually present with shortness of breath, cough, and chest pain [ 6 ] secondary to pleural effusions, which could be large and recurrent if the PPF is not treated.
The first step in the approach to a PPF is the determination of the pleural fluid amylase level. Once an elevated amylase pleural level is confirmed, the next step is obtaining abdominal imaging with a MRCP. This modality is superior to abdominal computed tomography in visualizing the pancreatic parenchyma and ducts, pancreatic fluid collections, pseudocysts, and, occasionally, the fistula site, which could be extremely useful to determine the optimal therapeutic intervention [ 7 ].
Since PPF is uncommon, the management remains controversial, as there are no clinical studies that compare the available therapeutic options. If after 2 or 3 weeks of initiation of medical treatment there is no resolution, an endoscopic intervention should be attempted [ 1 ]. Endoscopic treatment aims to reduce the pancreatic-duodenal pressure gradient within the PD or pseudocyst by creating a pathway of least resistance into the duodenum [ 7 ].
This is achieved by placement of a transpapillary PD stent with sphincterotomy of the major papilla and pseudocyst drainage in patients with partial PD disruption or stricture [ 9 ]. Finally, surgical intervention is reserved for patients with failure of endoscopic management or for those who have complete PD disruption or severe stricture [ 11 ]. Endoscopic treatment for PPF, along with other modalities, has been described in the past [ 1 , 4 , 6 , 9 , 12 ].
It has been used in conjunction with somatostatin [ 4 , 12 ] and complemented with chest tube placement for drainage of large pleural effusions [ 1 , 4 , 6 ], nasopancreatic drainage [ 12 ], and surgical treatment if the latter fail to resolve the fistula [ 1 ].
In our case, we were able to resolve the recurrent large pleural effusions secondary to the PPF with the placement of a PD stent without need for complementary therapies. In conclusion, endoscopic treatment in patients with the presence of a pancreatic pseudocyst and a partial disruption of the PD, as in our case, can be a safe an effective approach.
National Center for Biotechnology Information , U. Am J Case Rep. Published online Jul 5. Find articles by Marco Antonio Bustamante Bernal. Find articles by Jose Lisandro Gonzalez Martinez. The patient had no history of drug and alcohol intake or abdominal trauma. Chest tube was inserted for three weeks, during this period the clinical symptoms such as dyspnea and chest pain improved but not completely.
Thedaily drain output was about cc at the first day of chest tube insertion but it decreased gradually. No evidence of pancreatic duct dilatation or common bile duct dilatation was seen.
Therefore external psendocyst drainage was done with mushroom insertion. Mushroom was removed after one week when no drainage was seen. Finally the patient was discharged after 40 days of hospitalization. Intrathoracic neoplasms, trauma, bleeding diathesis or tuberculosis may cause hemorrhagic pleural effusion as well [ 1 ].
Right-sided hemorrhagic pleural effusion as the sole manifestation of pancreatitis is rare [ 1 — 4 , 6 , 7 ] especially when it occurs in the non-alcoholic patient under the age of 20 [ 2 , 3 ]. The postulated pathogenic mechanisms for hemorrhagic effusions include transdiaphragmatic transfer of fluid via lymphatics, diaphragmatic perforation of pseudocyst and mediastinal extension [ 1 ].
Several studies demonstrated that a fistula connecting a pancreatic pseudocyst with pleural cavity was the mechanism of pleural effusion [ 4 , 7 ]. Although the cause of pancreatitis could not be identified in our study, other studies have shown that pleural effusion with a very high pancreatic enzymes activity most frequently occurs in patients with alcoholic pancreatitis [ 5 , 8 — 10 ]. Pleural effusions due to pancreatic diseases are mostly reactive with slightly elevated amylase levels.
Very high levels of amylase in the pleural fluid are rare and can only be explained by the rupture of a pancreatic pseudocyst with perforation into the pleural cavity such as by drainage of pancreatic fluid into the pleural cavity [ 11 ]. Regarding elevated pleural fluid amylase, perforation of pseudocyst into the pleural cavity seems to be the mechanism of hemorrhagic pleural effusion in this case.
The other causes of hemorrhagic effusions with an increased amylase include traumatic esophageal rupture and intrathoracic and other neoplasms [ 1 ]. In most cases, the pleural effusion occurs concomitantly with the signs and symptoms of pancreatitis, but may occur even after the acute abdominal symptoms have subsided.
Considerable diagnostic problems may be encountered in cases in which the clinical picture is dominated by the pleuro-pulmonary symptoms, and the pancreatic condition remains completely or partly in the background [ 12 ]. An early and rapid diagnosis can be made by the examination of the pleural fluid for elevated amylase [ 2 ].
Visual methods such as computed tomography, ultrasonography, endoscopic retrograde cholongiopancreaticography ERCP are also useful [ 5 ]. Treatment with drainage by a chest tube, with concomitant conservative treatment of the pancratitis, is usually effective in massive pancreatic pleural effusions. If drainage by a chest tube fails, percutaneous catheter drainage of the abdominal pseudocyst can be considered for treatment [ 11 ].
Pancreatitis should be taken into consideration when hemorrhagic pleural effusion occurs, especially when it occurs concomitant with elevated amylase level of pleural fluid.
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