[Massive pleural effusion complicating chronic pancreatitis. Treatment by endoscopic closure of a pancreatic-mediastinal fistula].
METHODS
A 53-year-old man was admitted because of anuria, dyspnea and a septic temperature. The patients' history included chronic alcoholism, chronic pancreatitis, COPD and a right nephrectomy because of nephrolithiasis. Urosepsis was initially suspected.


METHODS
The patients' clinical condition and nutritional state were severely reduced. Laboratory findings revealed severe systemic inflammation (leucocyte count: 22.4/nl, CRP: 324 mg/l). Computed tomography showed a large left-sided pleural effusion, encapsulated abdominal fluid below the diaphragm and alongside the pancreatic tail. After aspiration of the pleural effusion the diagnosis of an exsudate with elevated concentration of lipase (56,000 U/l) was confirmed. Endoscopic ultrasound showed a 3-4 cm pseudocystic mass originating in the region of the pancreatic tail. The ERP depicted chronic pancreatitis with strictures and destruction of the pancreatic duct. Two fistulae were identified, one proximal to a ductal stricture in the pancreatic head and a second one in the pancreatic tail which corresponded to the reported pseudocyst.


METHODS
The patient was admitted to the ICU with symptoms of impending sepsis. The pleural effusion was treated with CT-guided chest drainage. The initial endoscopic attempt at stent closure of the fistula failed because it was possible to pass through the ductal stricture only with a thin hydrophilic wire and small-lumen catheter. However, injection of fibrin glue into the proximal pancreatic duct over a length of 2 cm obliterated the fistula and the pleural effusion was resolved.


CONCLUSIONS
Pancreatic-pleural or pancreatic-mediastinal fistula is a rare complication of pancreatitis associated with unilateral pleural effusion. Combined internal endoscopic drainage and external chest drainage is the treatment of choice. After failure of routine endoscopic therapy, endoscopic closure of fistulas using fibrin glue might offer an alternative treatment strategy.
Trudzinski
F C
FC
Universitätsklinikum des Saarlandes, Klinik für Innere Medizin V, Kirrbergerstr. 1, 66421 Homburg. franziska.trudzinski@uks.eu
Rädle
J
J
Treiber
G
G
Kramm
T
T
Sybrecht
G W
GW
D004322:Drainage / Q000379:methods; D016145:Endoscopy, Digestive System; D015718:Fibrin Tissue Adhesive / Q000008:administration & dosage; D006801:Humans; D008297:Male; D008477:Mediastinal Diseases / Q000150:complications / Q000000981:diagnostic imaging / Q000628:therapy*; D008875:Middle Aged; D010183:Pancreatic Ducts; D010185:Pancreatic Fistula / Q000150:complications / Q000000981:diagnostic imaging / Q000628:therapy*; D010192:Pancreatic Pseudocyst / Q000000981:diagnostic imaging; D050500:Pancreatitis, Chronic / Q000150:complications*; D010996:Pleural Effusion / Q000000981:diagnostic imaging / Q000209:etiology* / Q000628:therapy*; D014014:Tissue Adhesives / Q000008:administration & dosage; D014057:Tomography, X-Ray Computed; D014463:Ultrasonography
D015718:Fibrin Tissue Adhesive; D014014:Tissue Adhesives