Chronic massive pancreatic pleural effusion.

Chronic massive pancreatic pleural effusion. N A Dewan, W W Kinney and W J O'Donohue, Jr Chest 1984;85;497-501 DOI 10.1378/chest.85.4.497 The online version of this article, along with updated information and services can be found online on the World Wide Web at: http://chestjournal.chestpubs.org/content/85/4/497

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ChronicMassivePancreaticPleural Effusion* Naresh

A. Dewan,

WalterJ.

M.D.,

F.C.C.P.;t

O'Donohue,Jr,

Wesley W Kinney,

M.D. , F.C.C.P.;@ and

M.D., F.C.C.P.@

Chronic massive pancreatic pleural effusion is an uncom mon and often unrecognized clinical syndrome which results

priate

from

chronic massive pancreatic

an internal

pancreatic

fistula

and usually

presents

as

an exudative effusion of unknown cause. The effusion frequently

occurs

without

clinical

evidence

of pancreatitis,

but occasoinally it may be associated with a pseudocyst of the pancreas. Chronic massive pancreatic pleural effusion is usually recurrent and characterized by very high levels of amylase in the pleural fluid. Morbidity and mortality are

C

hronic massive pancreatic

pleural effusion due to

an internal pancreatic fistula is a syndrome which is infrequently

recognized

and diagnosed.'@7 The effu

sion tends to be recurrent and is characteristically

reduced when a definite diagnosis is established therapy

rendered.

In this

report,

and appro

three

cases

of

pleural effusions are presented.

Two of the three had no demonstrable pancreatic disease, and the condition responded to conservative therapy. The third patient had a pancreatic

pseudocyst

and an internal

pancreatic fistula which was corrected only after multiple surgical

procedures.

man with blood pressure of154/92 mm Hg, pulse rate oflOObeats per minute,

respiration

rate of 24/mm,

and temperature

of 37.2Â°C

(99Â°F).The percussion note was dull, and breath sounds were decreased moderate

over the left pulmonary base. Chest x-ray films revealed a left-sided pleural effusion. Dark brown exudative fluid

exudative with very high levels of amylase. Morbidity and mortality can be reduced through appropriate evaluation therapy. The purpose ofthis report is to present three cases of chronic massive pancreatic pleural effusion, each having a different clinical course. In the first case, which has been reported elsewhere,6 there was no evidence of pancreatic disease, and no specific studies were done to attempt to demonstrate an internal pancreatic fistula. The second patient had a large pancreatic pseudocyst with a definite communication between the abdominal cavity and the right pleural space. The last patient had loculated pleural and mediastinal effusions with no detectable pancreatic

with an elevated concentration of amylase was removed by thoraco

lesion, and the condition responded to conservative

The patient's dyspnea improved after a fourth thoracocentesis, but increased again on the sixth day of hospitalization when a repeat

management. The common denominator in all three cases was massive exudative effusion with very high levels of amylase in the pleural fluid. CASE CASE

REPORTS

centesis (â€˜Bible1), resulting in symptomatic improvement. The findings from urinalysis, complete blood cell count, and tests of hepatic function were normal. On the 13th day a second thoracocen tesis was done (Table 1) because of increased orthopnea. A skin test

with purified protein derivative oftuberculin (PPD) was positive at 48 hours. Multiple examinations of sputum showed no acid-fast

bacteria on smear or culture. Abdominalultrasoundand computer ized tomograms ofthe abdomen and thorax demonstrated

gallstones

and a left-sided pleural effusion. The patient was discharged and then readmitted two weeks later, at which time a third thoracocen tesis was performed

for reliefoforthopnea.

Multiple pleural biopsies

showed only nonspecific pleuritis, and cultures of pleural tissue for aerobic bacteria, fungi, and mycobacteria showed no growth. Approximately one week later, the patient was readmitted for the third time because of recurrent dyspnea, and the physical examina lion demonstrated findings of increased left-sided pleural effusion.

chest x-ray film disclosed

near-total

fluid opacification

of the left

hemithorax (Fig 1).A chest tube thoracostomy drained 3.5 L initially and an additional liter offluid over the next three days. On the third day ofchest

tube drainage,

the patient@ temperature

rose to 38.9Â°C

Table 1â€”Findingsfrom Pleural Fluid in Patient 1

1

A 49-year-oldman was admitted to the OmahaVeteransAdminis tration Medical Center because of chronic alcohol abuse. On the third day of hospitalization, he complained of orthopnea and pleuritic left-chest pain. Physical examination disclosed an obese *From the Department ofMedicine, Creighton University School of Medicine, and Medical Service, Veterans Administration Medical Center, Omaha. tAssistant Professor of Medicine and Acting Chief, Pulmonary Medicine, Omaha Veterans Medical Center. tPulmonary Medicine Fellow. Â§Professor of Medicine and Chief, Pulmonary Medicine. Manuscript received August 29; revision accepted October 10.

Admission 55)Volume,DataDay

3Day

Admission

13Second (Day 44)Third (Day

L0.82.02.03.0Protein, g/dl43.83.53.54LDH,IU/ml264. .300Amylase,

.

..

.

IU/L6,50019,40026,00047,400Serum amylase, IU/L*423530.

.

.380

Reprint requests: Dr Dewan, Section of Pulmonary Medicine, Creighton

University,

601 North 30th Street, Omaha 68131

*Normal range, 20 to 110 IU/L. CHEST I 85 I 4 I APRIL 1984


497

lower thorax failed to demonstrate pancreatic edema or a pseudo cyst Multiple thoracocenteses followed by chest tube drainageand total parenteral nutrition were associated with resolution of the pleural effusion.

CASE2 A 37-year-old white man with a known history ofpancreatitis

was

hospitalized because ofincreasingshortness ofbreath and pain in the left upper quadrant. He had a history of excessive consumption of

alcohol for several years. On admission the patient was in mild respiratory distress with a

FIGURE 1. Chest x-ray film obtained at time of third admission,

showing massive left-sided pleural effusion (case 1). (102Â°F);however, cultures ofblood, urine, sputum, and pleural fluid were sterile. Two days after the onset of fever, the chest tube

drainage was minimal, and the tube was removed after six days. Differential cell counts ofthe pleural fluid disclosed white blood cell counts of 1,000/cu mm to 2,000/cu mm, with 75 to 80 percent mononuclearcells. Levels ofamylase in the pleuralfluidrangedfrom 6,500 to 47,400 IU/L, while the highest serum level ofamylase was 530 IU/L (Fable 1). For three weeks the patient received total parenteral nutrition and intravenous cimetidine with no oral intake. He wasdischargedafterfourweeks and has remainedasymptomatic. At discharge and after three months, the chest x-ray film revealed only residual pleural reaction on the left. Comment: Although there was no attempt to demonstrate an internal pancreatic fistula, we believe that it was the most likely

cause for the recurring massive pleural effusion with high amylase content.

A computerized

tomographic

scan of the abdomen and

respiratory rate of 24/mm, normal temperature, blood pressure of 140/80 mm Hg, and pulse rate of 80 beats per minute. There was marked dullness to percussion, with complete absence of breath sounds over the right hemithorax. Chest x-ray film revealed massive right-sided pleural effusion (Fig2). Abdominal examination revealed alarge cystic mass, extending fromthe xiphoid to the umbilicus and across the entire upper abdomen. Three thousand one hundred milliliters of yellow-green exudative fluid was drained by thoraco centesis. The amylase level ofthe pleural fluid was 8,100 IU/L, and the serum level of amylase was 151 lU/L (normal, 25 to 110 lU/L).

Cram stain and cultures ofpleural fluid were negative for aerobic and anaerobic bacteria. An additional 3,000 ml offluid was removed by thoracocentesis on the following day, resulting in significant relief of dyspnea. A computerized tomographic scan ofthe lower thorax and upper abdomen showed a moderate pleural effusion and a cystic mass in the upper abdomen close to the midline and pancreatic edema. A consulting surgeon decided to perform an exploratorylaparot omy. A chest tube was inserted in the operating roomjust prior to surgery and drained 2,500 ml ofpleural fluid, with reduction in the abdominal swelling. At laparotomy the pancreas was noted to be markedly inflamed, and no pseudocysts or fistulous tracts were identified. Surgical pancreatography was not peformed. After sur gery the patient received total parenteral nutrition and intravenous cimetidine for two weeks. He developed an infection in the pleural

space which was treated with antibiotics. Despite these measures, the patient continued todopoorly, andthere waspersistent drainage of 350 to 400 ml from the chest tube. An endoscopic retrograde cholangiopancreatogram demonstrated good filling of the common biliary duct and an accessory pancreatic duct, but the main pancre atic duct was not visualized. The chest tube was removed despite the presence ofa hydropneumothorax,and the patient was discharged after 40 days of hospitalization. The patient was readmittedtwo monthslaterbecause ofincreasing shortness ofbreath and recurrence ofpleural effusion. At this time, he was referred to the Mayo Clinic where, after extended observa tion, he underwent rightthoracotomy and decorticationofthe lung, diaphragm, and mediastinum. A 2-mm fistulous tract draining clear fluid richin amylasewas noted to extend fromthe rightpleuralspace

into the abdomen.This tractwas oversewnby the surgeon.The patient had a complicated postoperative course, necessitating total parenteral nutrition to improve nutrition. Multiple computerized tomographicscansofthe abdomen demonstrated slow resolution of the cystic masses in the pancreas. The patient was discharged four weeks later. Achest x-rayfllm at discharge demonstrated pleural and parenchymal scarring, with no evidence ofpleural fluid.

The patient was readmitted six weeks later because of increasing abdominal swelling. A computerized tomographic scan of the abdomen demonstrated a large discrete pancreatic pseudocyst (Fig 3), which was internally drained into the stomach through a gastropseudocystostomy. After surgery the patient did well and was

â€˜¿4:

discharged two weeks later. A chest x-ray film obtained six weeks

after discharge showed no pleural fluid.

FIGURE 2. Chest x-ray film at time of admission, showing massive

right-sided pleural effusion (case 2).

498

Comment: This patient had pancreatitis with an abdominal pseu docyst and pancreatic pleural effusion. Three major surgical proce dures were performed in order to resolve the problem. Chest tube

ChronicMasshmPancreaticPleuralEffUSIOn (Dowan,Kinney.O'Donohue)


Table 2â€”Datafrom Pleural Fluid and Serum in Patient 3 3Volume,DataAdmissionDay

2Day

L1.81.50.4Protein, g/dl3.83.92.9LDH,

lU/L23632464Amylase, lU/L10,29517,9007,750Serum amylase, IU/L@1,179.

.

.145

*Normal range, 20 to 110 IU/L. amylase. Gram stain and cultures of pleural fluid were negative for

aerobic and anaerobic bacteria. Acid-fast and fungal stains and cultures were also negative. The sputum grew many organisms of Hemophilus influenzae. The patient was treated with intravenous ampicillin (1 g every four hours for ten days). A leukocytosis of

25,000/cu mm with a leftward shift was noted. The serum level of amylase was elevated (Table 2). A skin test with PPD was negative. A repeat thoracocentesis with pleural biopsy was performed. The pH

of the pleural fluid was 7.14, and the pleural biopsy showed acute organizing

pleuritis

with no evidence

of malignancy.

A chest tube

was inserted on the third day ofhospitalization, and 400 ml of fluid FIGURE

3. Abdominal

ing large

pancreatic

computerized

tomographic

pseudocyst

which

scan

increased

was drained initially,followedby 150ml over the next two days.

demonstrat

in size after

thoracotomy (case 2). drainage

accompanied

by infection

in the pleural

space failed to

prevent the reaccumulation of pleural fluid. A fistulous tract con necting the right pleural space to the abdominal cavity was demon strated during thoracotomy and decortication. The patient ul timately required the stomach. CASE

internal

drainage of a pancreatic

pseudocyst

into

3

A 59-year-old white man was admitted to the Omaha Veterans Administration Medical Center with increasing shortness of breath and cough productive ofyellow and white sputum. On admission, he was in moderate respiratory distress with a respiratory rate of 44/mm, pulse rate of 140 beats per minute, and temperature of 37.4Â°C(99.4Â°F). Decreased breath sounds and dullness were noted

over the right lower portion of the chest. A chest x-ray film demonstrated a moderate pleural effusion in the right hemithorax (Fig4). A thoracocentesis performed on the day ofadmission yielded 1,850 ml of serous exudative

fluid (Table 2) with a high level of

There was no further drainage over the next four days, and a chest x-ray film showed small amounts of loculated pleural fluid posteri orly. The patient was treated empirically for acute pancreatitis, with

intravenous fluids and cimetidine, and his symptoms improved signfficantly

4. Chest

x-ray

film at time

pleural effusion (case 3).

ofadmission,

showing

right-sided

fifth day of hospitalization.

Computerized

of loculated pleural fluid in the right hemithorax and also a large subcarinal mass which was believed to represent loculated fluid in the mediastinum (Fig 5). There was no evidence of pancreatic

inflammation. A barium swallow failed to reveal any esophageal pathologic findings. No endobronchiallesion

was noted on fiberoptic

bronchoscopy. A regular diet was resumed, with no increase in pleural fluid or worsening ofsymptoms.

Since the patient's condition

continued to improve, it was decided to defer thoracotomy and observe the loculated mediastinal fluid. He was discharged a week after the chest tube had been removed, and a chest x-ray film obtained four weeks later showed some residual pleural thickening.

A repeat computerized tomographic scan of the thorax and upper abdomen mass.

FIGURE FIGURE

by the

tomography ofthe abdomen and thorax demonstrated small amounts

demonstrated

5. Thoracic

complete

computerized

subcarmnal mediastmal

resolution

tomographic

fluid density

of the mediastinal

scan

demonstrates

which is probably

loculated

mediastinal effusion (case 3). CHEST I 85 I 4 I APRIL 1984


499

Comment: Although an internal pancreatic fistula was not demon strated, computerized tomographic scans of the thorax and upper abdomen revealed a subearinal mediastinal mass which was most likely loculated mediastinal fluid or possibly a mediastinal pseudo cyst. Nonsurgical treatment was successful in the management of the pleural and mediastinal fluid.

pleural fluid have been noted in pancreatitis and in thoracic neoplasms, both primary and secondary.2 Very high levels of salivary amylase may occur with esophageal rupture,9 but the clinical presentation and

natural history usually make this easy to differentiate from chronic massive pancreatic pleural effusion.â€¢ Thus, measurement of the level of amylase in the

DIsCussIoN

pleural fluid should be done in all exudative pleural Small transient pleural effusions occur in 4 to 17 percent of patients with acute 1The effu sion is usually left-sided and has a normal or mildly elevated amylase content. Typically, it is an asympto matic nonhemorrhagic effusion that clears as the acute pancreatitis resolves. Chronic massive pa@icreatic pleural effusion may develop weeks, months, or years after an episode of acute pancreatitis, and in the majority ofthe patients, there is no history of pancreatic disease.3 Patients commonly present with pulmonary complaints of dyspnea, cough, and chest pain. Most patients do not have abdominal symptoms, but some may have abdom

inal tenderness

or swelling. The serum level of

amylase is usually normal or only mildly elevated. When the serum level of amylase is increased, it is thought to be due to back diffusion from the pleural space rather than acute pancreatic inflammation.4 The concentration of amylase in the pleural fluid is always markedly elevated, usually greater than 1,000 lU/L,

with reported values as high as 475,000 Somogyi units/ 7

The

pleural

concentrations

fluid

is

of protein

an

exudate

with

elevated

and lactic dehydrogenase

(LDH). Recurrence of the effusionafterrepeated thoracocentesis is characteristic, and this was apparent in the three cases presented. Chronic massive pancreatic

pleural effusion is due,

in most cases, to posterior disruption ofthe pancreatic duct into the retropenitoneal space, with tracking of pancreatic secretions along the esophagus or aorta up ward into the mediastinum. Penetration into one or both pleural spaces results in unilateral or bilateral pleural effusions. Less commonly, secretions are con tamed within the mediastinum and present as a medi astinal pseudocyst.8 In patient 3, there was a large subcaninal mediastinal mass on the computerized tomographic scan, which was due to a loculated medi astinal effusion or a pseudocyst. Formation of a fistula from an abdominal pseudocyst, directly through the dome ofthe diaphragm and into the right or left pleural

cavity, has also been reported,5 and this was evident in patient 2. A major piffall in the diagnosis and management of chronic massive pancreatic pleural effusion is failure to recognize that intra-abdominal disease is responsible for the pleural effusion. The most important clue is the very high level ofamylase

elevations 500

in the pleural

in the concentration

fluid. Lesser

of amylase

in the

effusions

of unknown

tion is markedly setting,

cause,

elevated

a diagnosis

and when that concentra

in the appropriate

of chronic

massive

clinical

pancreatic

pleural effusion should be strongly considered.

Therapy is somewhat controversial, but because of its demonstrated cases, conservative

effectiveness management

in 48 percent of the should be attempted

initially.3 All three patients were maintained with no oral intake and received total parenteral nutrition and intravenous cimetidine for periods of one to three weeks. Repeat thoracocenteses patients for relief of dyspnea,

were required in two and all three patients

ultimately had chest tube drainage. Atropine, aceta zolamide, and nasogastnic suction have been advocated in the medical management ofchronic massive pancre atic pleural effusion34'Â° but are of unproven clinical efficacy. Medical management was successful in two of the three patients, while the third patient required several

surgical

procedures

In summary,

chronic

to resolve

massive

the problem.

pancreatic

pleural

effusion must be considered in the differential diag nosis ofmassive exudative pleural effusion of unknown

cause. The three cases presented provide a spectrum of the clinical presentation of chronic massive pancre atic pleural effusion. Marked elevation of the concen tration of amylase in the pleural fluid is virtually diagnostic in the appropriate clinical setting, and a trial ofnonsurgical therapy is successful in about one-half of the cases. If this fails, abdominal surgery may be lifesaving. Although infrequently reported, chronic massive

pancreatic

pleural

effusion

is probably

more

common than expected, and as awareness of the syn drome increases, more cases may be identified. ACKNOWLEDGMENT: We thank Eugene E Lanspa, M.D., and John D. Roehrs, M.D., for allowing us to include (patient two) in our report.

their patient

REFERENCES 1 McKenna J, Chandrasekhar A, Skorton D, Craig RM, Cugell DW. The pleuropulmonary complications of pancreatitis. Chest 1977; 71:197-204 2 Anderson WJ, Skinner DB, Zuidema C, Cameron JL. Chronic pancreatic pleural effusion. Surg Gynecol Obstet 1973; 137: 827-30 3 Cameron JL, Kieffer RS, Anderson WJ, Zuidema G. Internal pancreatic fistula: pancreatic ascites and pleural effusion. Ann Surg 1976; 184:587-93 4 Cameron JL. Chronic pancreatic ascites and pancreatic pleural effusion. Gastroenterol 1978; 74:134-40 5 Tombroff M, Loicq A, DeKoster JP, Engleholin L, Govaerts JP Chronic Massive Pancreatic Pleural Effusion (Dewan, Kinney, O'Donohue)


Pleural effusion with pancreaticopleural fistula. Br Med J 1973; 1:330-31 6 Marshall JB. Pancreatic

ascites and pleural effusion.

Med J 1982; 67:252-55 7 Kaye MD. Pleuropulmonary Thorax 1968; 23:297-306 8 Jaffe BM, Ferguson TB,

pancreatic

pseudocysts.

Am J Surg 1972; 124:600-06

9 Bellman MH, Rajanatnam HN. Perforation of the esophagus with amylase rich pleural effusions. Br J Dis Chest 1974; 68:

Nebraska

197-201 10 Field BE, Hepner

complications of pancreatitis.

GW, Shabot MM, Schwartz

AA, State D,

Worthen N, et al. Nasogastric suction in alcoholic pancreatitis. Holtz

S. Shields

Dig Dis Sci 1979; 24:339-44

JB. Mediastinal

14thAnnualFleischnerSocietySymposium The Fleischner Society will hold its 14th Annual Symposium on Chest Disease, June 17-19,at the Sweeney Convention Center, Santa Fe, New Mexico. For information, please contact Fleischner

Society Conference

Coordinator,

3770 Tansy, San Diego 92121 (619:453-6222).

John R WyattTravelingFellowshipin EnvironmentalPathology The University of Kentucky and the Kentucky Tobacco Research Board announce the John P Wyatt Traveling Fellowship in Environmental Pathology. Awards will be made for travel and associated

costs for studying

environmentally-caused

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Deadline

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15, 1984. The award will be effective August 1, 1984. For information, contact Mr. W. C. Royster,

Vice Chancellor for Research, University of Kentucky Graduate School, 359 Patterson Office Tower,

Lexington

40506-0027

(606:257-1663).

CHEST I 85 I 4 I APRIL 1984


501

Chronic massive pancreatic pleural effusion. N A Dewan, W W Kinney and W J O'Donohue, Jr Chest 1984;85; 497-501 DOI 10.1378/chest.85.4.497 This information is current as of July 13, 2011 Updated Information & Services Updated Information and services can be found at: http://chestjournal.chestpubs.org/content/85/4/497 Cited Bys This article has been cited by 5 HighWire-hosted articles: http://chestjournal.chestpubs.org/content/85/4/497#related-urls Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.chestpubs.org/site/misc/reprints.xhtml Reprints Information about ordering reprints can be found online: http://www.chestpubs.org/site/misc/reprints.xhtml Citation Alerts Receive free e-mail alerts when new articles cite this article. To sign up, select the "Services" link to the right of the online article. Images in PowerPoint format Figures that appear in CHEST articles can be downloaded for teaching purposes in PowerPoint slide format. See any online figure for directions.
