A pancreatico-pleural fistula diagnosed with magnetic resonance cholangiopancreatography

Pancreatico-pleural fistula (PPF) represents a rare complication of chronic pancreatitis, especially in patients with an alcohol abuse history. It results from the traumatic or inflammatory disruption of the main pancreatic duct or its side branches, leading to the formation of a fistulous tract between the pancreas and the pleural cavity through the esophageal or aortic hiatus of the diaphragm [1, 2]. We report a case of recurrent chronic alcohol-related pancreatitis evolving into a PPF in a young man who underwent magnetic resonance cholangiopancreatography (MRCP). CASE REPORT A 29-year-old man, with increasing dyspnea, mild abdominal epigastric discomfort, anorexia and an indefinite weight loss in the two months prior to hospitalization, was admitted to our hospital. Past medical history was relevant for chronic alcoholic pancreatitis, first diagnosed two years before the present admission. Physical examination was suggestive of a notable pleural effusion in the left pleural cavity and only mild pain was elicited on deep palpation of the epigastric region. Laboratory data were as follows: serum amylase 323 U/L (reference range: 8-53 U/L), lipase 516 U/L (reference range: 8-78 U/L) and calcium 7.9 mg/dL (reference range: 9-10.5 mg/dL). No biochemical signs of cholestasis or hepatocellular damage were found. The pleural effusion in the left pleural cavity was confirmed by chest X-ray. Abdominal ultrasound showed a moderately enlarged pancreas and a round fluid collection with a slightly thickened wall, 2 cm in size, located in the pancreatic body. A small amount of fluid was also noted in the omental bursa. With the clinical suspicion of a PPF, further evaluation by magnetic resonance (MR) and MR-cholangiopancreatography (MRCP) was requested. Abdominal MRCP was performed by a 1.5 T unit (Sonata Symphony Siemens, Erlangen, Germany) with a phased-array body coil. We used heavily T2-weighted sequences: a half-Fourier single-shot turbo spin-echo (HASTE) 2D breath-hold (relaxation time? 1,100 ms; time of echo 87 ms; slice thickness 4 mm; acquisition time 25 sec) and a turbo spin-echo (TSE) 3D respiratory gated (relaxation time 1,820 ms; time of echo 401 ms; thickness 4 mm; acquisition time 150) with multiplanar projection reconstruction (MPR) and multiple intensity projection (MIP). Axial scans of the upper abdomen with gradient echo fast low-angle shot (GRE FLASH) 2D T1 weighted and TSE T2-weighted sequences were also obtained. The TSE T2-weighted MR image showed a moderately enlarged pancreatic body with irregular contours and diffusely non-homogeneous signal intensity as well as a pancreatic body pseudocyst (black arrows) and main pancreatic ducct dilatation (grey arrows) (Image 1). The coronal scan HASTE 2D T2-weighted scan demonstrated a part of the proximal portion of the fistula (white arrow); an irregular dilatation of the main pancreatic duct side branches (black arrows) as well as pleural effusion in the left pleural cavity was also evident (asterisk) (Image 2). A PPF (Image 3, arrows), clearly demonstrated on the 3D MRCP sequence, appears on two different oblique MIP images as a high-signal intensity narrow structure arising from the pancreatic body pseudocyst (p) towards the left pleural cavity (asterisk). The diagnosis of PPF was confirmed by pleural fluid analysis, obtained by thoracentesis (amylase 7,137 U/L, lipase 27,000 U/L). Medical treatment was started with total parenteral nutrition (TPN) and the administration of large spectrum antibiotics, pancreatic enzymes, proton pump inhibitors and octeotride (500 µg bid i.m.). The patient was discharged, without dyspnea or abdominal symptoms, on medical therapy and TPN, in an improved general condition.