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Initial Experience of Pancreatico-Pleural Fistula, A Rare Complication of Acute on Chronic Pancreatitis with Challenging Diagnosis and Successful Management
* Corresponding author: Dr. Pavankumar Mansukhbhai Khunt, MBBS, MS, Department of General Surgery, Government Medical College and New Civil Hospital, Majura Gate, Surat, Gujarat, India. surajkhunt1292@gmail.com
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Received: ,
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How to cite this article: Khunt PM, Shah JB, Unjia AS, Shah DH. Initial Experience of Pancreatico-Pleural Fistula, A Rare Complication of Acute on Chronic Pancreatitis with Challenging Diagnosis and Successful Management. Int J Recent Surg Med Sci. 2025:11(e011). doi: 10.25259/IJRSMS_21_2025
Abstract
Pancreatitis is the most common morbidity in chronic alcoholic patients, with frequent abdominal and thoracic complications. Pleural effusion is a common complication of acute on chronic pancreatitis, but recurrent pleural effusion refractory to repeated thoracocentesis may raise suspicion of pancreatico-pleural fistula (PPF). For demonstration and treatment of such kind of fistula, radiological investigation and minimal invasive diagnostic and therapeutic treatment are needed. We presented three different cases of patients with PPF who came to the emergency department with difficult clinical presentation. Patients were primarily diagnosed with PPFs with pleural effusion. Patients were managed with intercostal drainage tube insertion and then underwent radiological investigation. After a thorough investigation, patients underwent minimally invasive procedures like Endoscopic Retrograde cholangiopancreatography (ERCP) with main pancreatic duct stenting for spontaneous closure of the fistula. All three patients required intercostal drainage tube insertion to drain effusion with intensive medical management. Patients were treated successfully with ERCP-guided main pancreatic duct stenting and managed conservatively for spontaneous closure of the fistula. In this case series, one patient had an unusual presentation and challenging diagnosis of acute pancreatitis with mediastinal pseudocyst extension with a bilateral PPF and severe mediastinitis. Another patient developed PPF after laparoscopic cysto-gastrostomy. The third patient developed PPF after the pancreatic pseudocyst ruptured into the left thoracic cavity, and was managed by ERCP-guided Main Pancreatic Duct (MPD) stenting for spontaneous closure of the internal fistula.
Keywords
ERCP
Main pancreatic duct
Pancreatico-pleural fistula
Pancreatitis
Pleural effusion
Thoracocentesis
INTRODUCTION
Chronic alcoholic patients frequently present with symptoms of pancreatitis. Transient left-sided pleural effusion is a more common complication of acute on chronic pancreatitis of either lymphatic or sympathetic origin, and most time exudative in nature. Pancreatico-pleural fistula (PPF) with severe chemical mediastinitis with mediastinal pseudocyst is a rare complication of acute on chronic pancreatitis, with predominant respiratory symptoms rather than abdominal symptoms. There is significant difficulty in diagnosing this condition. PPFs occur in acute or chronic pancreatitis and typically arise from the disruption of the main pancreatic duct, from a pancreatic pseudocyst, or sometimes due to traumatic pancreatic injury. PPF can develop after the successful management of a pseudocyst of the pancreas because of an unrecognized ongoing inflammatory process that leads to local inflammation and destruction. PPFs are more common on the left side of the thoracic cavity. In rare cases, it communicates with both pleural cavities and presents with bilateral gross pleural cavity effusion. This kind of pleural effusion is recurrent on repeated thoracocentesis, and patients need intercostal drainage tube insertion in both the chest cavities in case of a bilateral PPF. Biochemical analysis of aspirated pleural fluid shows higher levels of amylase and lipase as compared to the serum. Patients require radiological investigation, like contrast-enhanced computed tomography (contrast enhanced) scans of the abdomen-pelvis and thorax, magnetic resonance cholangiopancreatography (MRCP) study, ERCP-guided main pancreatic duct stenting for spontaneous closure of fistula.[1,2]
CASE SERIES
Case 1
PPF with mediastinal pseudocyst and severe mediastinitis
History
A 26-year-old male chronic alcoholic patient presented in the emergency department with a history of abdominal pain with chest pain, dry cough, and breathlessness for 14 days and 4 days of dyspnea on exertion and orthopnea. The patient presented with tachycardia of 120 beats per minute, tachypnea of 36/min, and a pulse oximetry reading of 86 saturation on room air. The patient was put on Non Re-Breathing Mask (NRBM) oxygen support. On clinical examination, air entry had severely decreased on both sides, and abdominal examination showed guarding. Chest X-ray demonstrated massive pleural effusion in the pleural cavity. Diagnostic left chest cavity thoracocentesis demonstrated markedly bloody, serosanguinous pleural fluid, which was sent for urgent biochemical, pathological, and culture sensitivity examination. The patient underwent urgent bilateral intercostal drainage tube insertion, which gradually drained pleural fluids from both chest cavities with continuous monitoring of vital parameters. The patient's vital parameters settled within 24 hours of emergency admission.
Pleural fluid culture sensitivity reports were suggestive of heavy growth of Klebsiella pneumoniae. The organism was sensitive to amikacin, tobramycin, gentamycin, and chloramphenicol.
Inj. octreotide was given to reduce pancreatic secretions.
Blood culture and sputum culture reports were negative.
MRCP report
This report showed a focal defect in the pancreatic parenchyma with communication of the pancreatic duct to the peripancreatic region, forming a thick-walled loculated collection likely representing a pseudocyst. It is abutting the posterior wall of the stomach and extending cranially along the gastroesophageal junction and lower esophagus into the posterior mediastinum through the esophageal hiatus in the diaphragm. The loculated collection in the posterior mediastinum is likely representing a pseudocyst extension.
A thin tract extending from the posterior mediastinal pseudocyst into both pleural cavities likely represents bilateral PPF formation.
CT Scan-ThoraxAbdomen Pelvis
These tests showed changes in acute-on-chronic pancreatitis with multiple intrapancreatic and peripancreatic collections.
Bilateral PPF with bilateral pleural effusion and bilateral inter-costal drainage tube (ICD) in situ with main-pancreatic duct (MPD) stent noted in situ.
Changes of mediastinitis in the form of extensive mediastinal fluid, fat stranding, ill-defined soft tissue infiltration, and mediastinal lymphadenopathy.
ERCP
Endoscopic diagnosis-main pancreatic ductal leak with bilateral PPF
Intervention
A 5 Fr pancreatic duct (PD) stent with multiple side holes was placed in the pancreatic duct for drainage. There was a free flow of pancreatic juice from the stent at the end of the procedure.
Recommendations
Intensive medical management. Stent assessment after 3 months. Five units of red blood cell concentrates (RCC) were transfused during admission.
Serial pleural fluid and blood level amylase and lipase were recorded, and both ICD fluid outputs decreased gradually after ERCP-guided MPD stent insertion, and both ICDs were removed successfully once output decreased to a minimal.
Follow-up ERCPPD stent removal after successful management of PPF
Endoscopic diagnosis
Chronic pancreatitis with PD stent in situ in c/o main pancreatic ductal leak with bilateral PPF
Intervention
Duodenoscopy revealed a patent SPT PD stent. The stent was removed with the help of a snare. Pancreatography revealed mild narrowing in the body with a dilated duct in the head and tail. The contrast drained easily; a new stent was placed.
Recommendations
Conservative treatment stent stent-free trial. W/F pain and collection. MRCP if needed. Repeat clearance with stenting SOS.
Case 2
PPF:- in previously o/c/o laparoscopic cystogastrostomy, followed by splenic artery embolization done for postoperative severe hematemesis in a non-alcoholic patient with challenging presentation in the emergency room, like lung abscess
History
A 35-year-old male non-alcoholic patient underwent laparoscopic cysto-gastrostomy 6 months ago for approx. 931 cc pancreatic pseudocyst arising from the body of the pancreas with average wall thickness measuring 56 mm. On the third post-operative day, the patient developed a severe episode of hematemesis that required urgent blood transfusion and CT-Angiography of the abdomen and pelvis to locate the source of bleeding. Later, the patient underwent splenic artery embolization for a small splenic artery aneurysm diagnosed on a CT-angiography. During the 6-month postoperative period, the patient was apparently well. After 6 months, the patient presented in the emergency department with a history of chest pain, productive cough, anorexia, severe weight loss, and 10 and 2 days of history of breathlessness and dyspnea on exertion. On clinical examination, the air entry had decreased in the left lower zone. Chest X-ray demonstrated loculated effusion with underlying collapsed and consolidated left lung, P/O-lung abscess. Diagnostic left chest cavity thoracocentesis demonstrated purulent output. The patient underwent left intercostal drainage tube insertion. The ICD drain fluid was sent for routine pathological, biochemical, and culture sensitivity examination. The patient was subjected to CECT-abdomen-pelvis-thorax for further diagnosis.
The pleural fluid culture sensitivity report suggested heavy growth of Pseudomonas aeruginosa.
The patient needs higher antibiotics in the form of Inj. meropenum, Inj. clindamycin, Inj. gentamycin, Inj. tigecycline, Inj. amikacin, Inj. piperacilinetazobactum, Inj. ceftazidimeavibactum, Inj. voriconazole, Inj. levofloxacin
Inj. octreotide was given to reduce pancreatic secretion, and total parenteral nutrition was started.
Potassium Hydrocloride for fungal elements: Negative
Blood culture and sputum-cartridge based nucleic acid amplification test (CBNAAT) and culture report came negative.
The patient presented with electrolyte imbalance, so correction was given as per need.
CT SCAN-ThoraxAbdomenPelvis
A peripherally enhancing collection with e/o air foci within it subdiaphragmatic region along the superior surface of the spleen.
Above mentioned collection appears to be communicating with the stomach lumen via a discontinuity involving the posterior wall of the stomach. s/o- post-operative changes related to cysto-gastrostomy.
Above mentioned sub-diaphragmatic collection appears to communicate with the pleural cavity via 1.5 cm. size rent and collection within the pleural cavity with adjacent collapsed lung parenchyma noted. The pancreas shows inhomogeneous post-contrast enhancement with foci of calcification in the distal body and tail region. Peri-nephric fluid with adjacent fat stranding and facial thickening noted on the left side. Multiple collaterals noted.
On administration of oral contrast, contrast is seen in the intrathoracic collection in the left pleural cavity.
Overall p/o changes of acute on chronic pancreatitis with subdiaphragmatic collection & intrapleural rupture with collection formation in the pleural cavity. Chronic splenic vein thrombosis. Ground-glass opacity (GGO) density nodules noted involving bilateral lung parenchyma, predominantly on the right side. P/o infective etiology.
Patient managed conservatively with ICD insertion and antibiotics
CT Scan-ThoraxAbdomenPelvis (Follow-up)
Approx. (5.1 2.4 3.2 cm) 21 cc sized peripherally enhancing fluid density lesion with air fluid level, noted adjacent to the superior surface of the spleen in the left subdiaphragmatic region.
Minimal amount of free fluid noted in the left costophrenic recess with few air foci.
The left hemi-diaphragm shows focal discontinuity measuring 9 mm and communication between the above mentioned collection and the pleural fluid.
ICD noted passing through the lateral aspect of the 9th intercostal space on the left side.
Pancreatic parenchyma appears atrophic and shows inhomogeneous post-contrast enhancement with multiple foci of calcification in the distal body and tail region. Main Pancreatic duct stent in situ.
The extrahepatic part of the portal vein appears to be replaced by multiple venous collaterals, which show normal post-contrast pacification. No e/o any thrombosis within the collateral noted.
Multiple collaterals noted involving peri-portal, peri-pancreatic, gastro-splenic, peri-gastric, and mesenteric regions.
Minimal amount of fluid noted in the pelvic and peritoneal cavity.
Mild omental and mesenteric haziness noted in the upper abdomen.
Case 3
The main pancreatic duct communicating pseudocyst spontaneously ruptured into the left thoracic cavity, presenting with gross pleural effusion
History
40-year-old male chronic alcoholic patient, previously diagnosed case of pancreatic duct communicating pancreatic pseudocyst arising from the head and body region of the pancreas. We put the patient on observation, as cyst wall maturity was not there. The patient suddenly presented to the emergency department with a history of loss of abdominal bulge with chest pain, dry cough, and breathlessness for 3 days, and history of dyspnoea. for 2 days on exertion and orthopnea. Patients presented with tachycardia of 110 beats per minute, tachypnea to 32/min, and with a pulse oximetry reading of 90 saturation on room air. The patient was put on oxygen support. On clinical examination, air entry was severely decreased on the left side, and abdominal examination showed mild epigastric tenderness with loss of the epigastric lump that was felt previously. Chest X-ray demonstrated gross pleural effusion in the left pleural cavity. Diagnostic left chest cavity thoracocentesis demonstrated markedly bloody, serosanguinous pleural fluid; the fluid was sent for urgent biochemical, pathological, and culture sensitivity examination. The patient underwent urgent left-sided intercostal drainage tube insertion with gradually draining pleural fluids from the left chest cavity with continuous monitoring of vital parameters. Patient's vital parameters were settled within 24 hours of emergency admission.
Inj. octreotide was given to reduce pancreatic secretion.
Pleural fluid, Blood culture, and sputum culture reports came negative.
MRI with MRCP (Before presenting as PPF)
Fairly large well well-defined loculated pancreatic measuring approximately 9.6 15.5 11.5 cm in the pancreas and peri-pancreatic region, and continue with the pancreatic duct at the neck and proximal body region, these likely represent a pancreatic pseudocyst.
Multiple vascular collaterals in the splenic hilum and gastro-splenic region.
Ct Scan-ThoraxAbdomenPelvis
Pancreatic parenchyma appears atrophic and shows inhomogeneous post-contrast enhancement with multiple foci of calcification in the distal body and head region, with a small amount of peripancreatic collection. Small subdiaphragmatic collection noted in relation to the peripancreatic collection.
Left hemi-diaphragm shows focal discontinuity measuring 56 mm, which shows communication between subdiaphragmatic peripancreatic collection and pleural fluid.
ICD noted passing through the lateral aspect of the 6th intercostal space on the left side with minimal to mild left pleural effusion [Table S1 and S2].
ERCP
Endoscopic diagnosis
Main pancreatic ductal leak with left-sided PPF
Intervention
A 7 Fr PD stent with multiple side holes was placed in the pancreatic duct for drainage. There was a free flow of pancreatic juice from the stent at the end of the procedure.
Recommendations
Intensive medical management. Stent assessment after 3 months.
Three units of RCC were transfused during the course of admission.
Serial pleural fluid, blood level amylase, and lipase were recorded, and left-sided ICD fluid output decreased gradually after ERCP-guided MPD stent insertion.
ICD was removed successfully once the output decreased to a minimal.
Follow-up ERCPPD stent removal was done after successful management of PPF.
DISCUSSION
PPF is a rare complication arising from acute or acute-on-chronic pancreatitis secondary to heavy alcohol abuse, with a confusing diagnosis, which mainly presents as respiratory and cardiovascular instability rather than abdominal symptoms, leading to late diagnosis and challenging management. The patient mainly presented with chest pain, shortness of breath, and a dry cough, which led to a delayed diagnosis and allowed for the development of complications such as lung entrapment.[2] Simple pleural effusion due to pancreatitis is because of a sympathetic chemically induced diaphragm-pleural inflammatory process. Pleural fluid amylase and lipase levels are not significantly elevated compared to serum amylase and lipase levels, and the effusion subsides once the intra-abdominal inflammatory process resolves. However, a large pleural effusion due to an internal fistula (PPF) that is refractory to routine management requires both diagnostic and therapeutic thoracocentesis or intercostal drain (ICD) tube insertion, along with intensive medical, endoscopic, and surgical management.[3] Basic investigations directed toward the diagnosis include chest X-ray, ultrasound examination of the thorax and abdomen, CECT of the thorax, abdomen, and pelvis, with MRCP and endoscopic procedures such as ERCP performed as needed for both diagnostic and therapeutic purposes, along with appropriate blood and pleural fluid investigations. ERCP is a minimally invasive endoscopic procedure and the initial choice for both diagnostic evaluation and therapeutic pancreatic duct stenting in the conservative management of PPF. Conservative management after ERCP heals up to 50 of internal pancreatic fistulas and 70 to 90 of external pancreatic fistulas with intensive medical management, include broad spectrum antibiotics, enteral nutrition, and managing fluid and electrolytes imbalance, avoiding major surgical morbidity and mortality. Surgical management is less frequently required due to the availability of minimally invasive endoscopic procedures. However, it becomes necessary in cases where conservative management fails and is complicated by infection, septicemia, or progressive end-organ damage, despite intensive medical treatment. Given the high surgical morbidity and mortality, surgical intervention is reserved only for patients who do not respond to conservative management and exhibit deteriorating general and vital conditions.[1]
CONCLUSION
PPF is a rare and diagnostically challenging complication of acute or acute-on-chronic pancreatitis, primarily due to its presentation with respiratory and cardiovascular symptoms. Various investigations are required to support the diagnosis of PPF, including CECT of the abdomen, pelvis, and thorax, MRCP, and ERCP, which serve both diagnostic and therapeutic purposes. Uncomplicated cases are managed with ERCP and intensive medical treatment, while refractory or complicated cases require surgical intervention, which carries high morbidity and mortality.
Ethical approval
Institutional Review Board approval is not required.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
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