Isolated massive pleural effusion caused by pancreatico-pleural fistula

Massive pleural effusions are uncommon but well-documented complications of chronic pancreatitis, usually caused by the development of a pancreaticopleural fistula. The mechanism of the fistula formation is thought to be rupture of the pancreatic duct or pseudocyst.

In the past 7 years we have treated 5 patients with massive pleural effusion of pancreatic origin in the Surgical Department of Semmelweis University Medical School. 4 patients were males; the average age was 52 years (range: 46-59 years).

All 5 patients had a history of alcohol abuse and were admitted to the pulmonary department because of respiratory distress. Other symptoms such as abdominal pain, chest pain, or weight loss were not always present. The diagnosis was confirmed by a markedly elevated amylase level in the aspirated pleural fluid. Abdominal ultrasound, CT scan, and ERCP examinations were carried out in order to determine the cause of the pancreaticopleural fistula. Conservative (nonsurgical) treatment was effective within 3 weeks in only one case. The other 4 patients required surgical management. In 3 cases distal pancreatic resection with splenectomy and cholecystectomy was done. In one case cystojejunostomy was performed. All 5 patients have been cured with complete resolution of their pleural effusions.

Patients with large pleural effusions may have underlying pancreatitis with a pancreaticopleural fistula. It is important to establish this diagnosis because treatment may require operative interventions.