Pancreatopleural Fistula Presenting as Recurrent Right-Sided Pleural Effusion: A Case Report

Pancreaticopleural fistula (PPF) is a rare complication of acute or chronic pancreatitis, resulting from the disruption of the pancreatic duct and abnormal communication between the pancreas and the pleural cavity. Patients often present with respiratory symptoms rather than abdominal complaints, making diagnosis challenging and frequently delayed. We report a case of PPF presenting as a rapidly recurrent right-sided pleural effusion in a patient with recurrent alcohol-related pancreatitis. A 48-year-old man with a history of recurrent alcoholic pancreatitis presented with progressive dyspnea and pleuritic chest pain. Chest radiography demonstrated a moderate-to-large right pleural effusion. Diagnostic thoracentesis yielded 2 L of dark maroon exudative fluid with a markedly elevated amylase level of 70,476 U/L. Drainage was performed in a symptom-guided manner, with the procedure terminated after symptom improvement, and the patient was monitored for re-expansion pulmonary edema. Despite initial symptomatic improvement, the patient developed rapid reaccumulation of effusion within 24 hours, necessitating pigtail chest tube placement. Due to persistent loculated pleural collections and inadequate drainage, intrapleural alteplase and dornase alfa were administered. Magnetic resonance cholangiopancreatography demonstrated a fluid tract extending from the pancreas into the right pleural cavity, raising suspicion for a PPF. Endoscopic retrograde cholangiopancreatography revealed chronic pancreatitis with obstructing pancreatic duct stones and a ductal defect. Complete stone extraction, pancreatic sphincterotomy, and pancreatic duct stent placement were successfully performed. The patient experienced complete resolution of the pleural effusion, with no recurrence following stent removal. This case highlights the importance of considering PPF in patients with recurrent pleural effusions and a history of pancreatitis, particularly when pleural fluid amylase levels are markedly elevated. Early recognition and endoscopic intervention can facilitate definitive treatment, prevent recurrent hospitalizations, and avoid repeated invasive pleural procedures.