Abstract Introduction Pancreaticopleural fistula (PPF) is a rare complication of acute or chronic pancreatitis, occurring in 1% of cases. It involves leakage of pancreatic enzymes into the pleural cavity via a fistulous tract through the diaphragm, causing high-amylase pleural effusions and recurrent collections that mimic other thoracic conditions. Early diagnosis is vital to prevent respiratory failure, malnutrition, and sepsis. We report a case of PPF after acute alcoholic pancreatitis, emphasizing diagnostic hurdles and multidisciplinary care. Case Description A 52-year-old man with chronic alcohol abuse presented with severe epigastric pain radiating to the back, nausea, and vomiting suggestive of acute pancreatitis. Labs showed elevated serum amylase (1,200 U/L) and lipase (2,500 U/L); computed tomography (CT) confirmed pancreatic necrosis and peripancreatic collections. He received conservative treatment: nil per os (NPO), IV fluids, and analgesics. Two weeks later, he developed dyspnea and left chest pain. Chest X-ray revealed a massive left pleural effusion (70% hemithorax). Thoracentesis drained 1.5 L straw-colored fluid with amylase 5,000 U/L, indicating exudative effusion. Contrast-enhanced CT of thorax/abdomen identified a fistulous tract from the pancreatic tail through the diaphragmatic hiatus to the left pleural space, confirming PPF. Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and pancreatic duct stenting was done, plus thoracentesis, chest tube drainage, and nasojejunal feeding to reduce pancreatic stimulation. Serial imaging over four weeks showed effusion resolution and fistula closure; he was discharged stably after stent removal. Discussion This case highlights PPF’s subtle onset, with thoracic symptoms often masking abdominal signs, delaying diagnosis in ∼40% of patients. Pleural amylase 1,000 U/L is diagnostic, aided by imaging for tract visualization. First-line therapy includes somatostatin analogs and ERCP, succeeding in 70-80% of cases and averting surgery. Our patient’s quick improvement with endoscopy demonstrates minimally invasive benefits, especially in low-resource areas. Clinicians should suspect PPF in post-pancreatitis patients with unexplained effusions, urging prompt team-based intervention to curb complications. Rare yet illustrative, such fistulas stress vigilant follow-up for pancreatitis patients. This abstract is funded by: None
Gulraiz et al. (Fri,) studied this question.