Pancreatico pleural fistula

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  • Pancreatico-Pleural Fistula

  • Anatomy of PancreasRetroperitoneal structure found posterior to the stomach and lesser omentum It has a distinctive yellow/tan/pink color and is multilobulatedThe gland is divided into four portionsThe headThe neckThe bodyThe tailThe pancreas has an extensive arterial system arising from multiple sources and venous drainage follow the arterial anatomy

  • Pancreatic DuctMain duct (Duct of Wirsung) runs the entire length of pancreasJoins Central Bile Duct at the ampulla of Vater2 4 mm in diameter, 20 secondary branches

    Lesser duct (Duct of Santorini) drains superior portion of head and empties separately into 2nd portion of duodenumDrains the uncinate process and lower part of head

  • Blood Supply of Pancreases

  • PancreatitisPancreatitis is inflammation of pancreas in which pancreatic enzyme get activated in situ before releasing into duodenum and begin attacking the pancreasEtiology

    Alcohol consumption, Gall stone (most common)Other: Medication, Infection, trauma, metabolic disorder, IdiopathicPatient may presents with acute colicky abdominal pain associated with nausea, vomiting, anorexia, feverOn Examination tenderness in epigastric region with guarding and abdominal distension, tachycardia, hypotensionMost common complication is pseudocyst formation/ fluid collection

  • Pseudocyst of PancreasPseudocysts are best defined as a localized fluid collection that is rich in amylase and other pancreatic enzymes, that has a nonepithelialized wall consisting of fibrous and granulation tissueAppears after several week of pancreatitisMost common complication of pancreatitisPseudocyst can be single or multiple (17%)Site of cyst : lesser sac (M/C), duodenum, jejunum, colon spleenIn most of the cases pseudocyst communicating with pancreatic duct(80%)May give rise to form fistula tract with other cavities like pleura, peritoneal , skinPresents with swelling in epigastric region, abdominal pain, fever (if it is infected50 % of pseudocyst may show spontaneous resolutionIt can be treated by endoscopic management / surgical

  • IntroductionPancreaticopleural fistula is a condition in which pancreatic secretions drain directly into the pleural cavity. It occurs either as a complication in acute and chronic pancreatitis, or after traumatic or surgical disruption of the pancreatic duct.

    Incidence rate: 0.4% of patient with chronic pancreatitis2.5 4.5% of patient with pseudopancreatic cyst

  • EtiologyChronic alcoholism Chronic pancreatitis Pancreatic pseudocystTraumaIatrogenicNon- IatrogenicPancreatic duct anomalyCauses of Pancreatitis

  • Classification of Pancreatic fistula

  • Pathophysiology

  • PresentationAge group: 40 50 years / Male H/O chronic alcoholismAbout half of the patients do not have history of pancreatitis

    Most commonly patient with moderate to massive effusion presents with dyspnea, cough, chest pain, fever (chest discomfort)Pulmonary symptoms are more common than abdominal symptoms as a presenting symptomsRarely do patients complain of abdominal pain (25-30%)The average duration of symptoms is 5-6 weeks

  • On ExaminationPercussion: DullnoteAuscultson : Decreased breath sounds

    Pleural effusion are predominately left sided; however, right-sided and bilateral effusion can occursAs there is PPF, Pleural effusion of this nature tends to be large and recurrent despite repeated thoracocentesis.Delay in diagnosis

  • InvestigationChest xrayS/O fluid collection in pleural cavity

    Pleural fluid AnalysisPleural fluid amylase, lipase >1000 U/L - most important diagnostic testhigh albumin content (>3g/dL)

  • CT scan of the chest and abdomen

    Gold standard for pleural effusionvery useful in determining the site and size of effusionCT abdomen in addition will reveal changes of pancreatitis and identify other associated abnormalities such as pancreatic pseudocystsbut overall ability to provide accurate delineation of the fistula is disputable

  • MRCP(Magnetic resonance cholangial pancreaticography)

    Visualizes the duct beyond the strictures, depicts parenchymal atrophy, ductal anatomy and small intrapancreatic and extrapancreatic pseudocyst, peripancreatic collection, or pancreaticopleural fistula.noninvasive alternative to ERCPuseful where ERCP fails to give adequate informationDisadvantage : Only diagnostic, No therapeutic role

  • ERCP (Endoscopic Retrograde Cholangiopancreatography)

    provides information about the ampulla besides depicting ductal anatomyMoreover, with the advent of pancreatic duct stents, ERCP attains a therapeutic role as wellIt fails if fistula is located beyond the site of obstruction

  • Treatment Available Treatment modalities

    Conservative/medical managementThoracocentesisOctreotideERCP / Endoscopic managementERCP StentingDuct dilationSphinterectomyNasopancreatic drainSurgery

  • Conservative/Medical managementAimTo reduce Pancreatic stimulation/SecretionDrianage of FluidConstitute of Thoracocentesis/Tube thoracostomyencourage apposition of serosal surfacesSomatostatin analogue OctreotideInhibits exocrine secretion.No effect on closure rate.Reduces output and improves fistula controlStart with 50MCG tds and then adjust the dose according to drain output.

  • ERCP/Endoscopic managementAim : Relive the obstruction site/ bypass disruption siteachieve drainage of ducts with fistulae in short term and drainage of the stenosed pancreatic duct in long termConstitute ofpapillary sphincterotomy - sphincter of Oddi dysfunctiondilatation of stenosis Stricture/obstruction of pancreatic ductextraction of stones from duct with/without lithotripsyPancreatic stenting disruption of ductAdvantagePain due to increased duct pressure gets reducedPseudocyst that communicating with duct may get drained It also allows us to do cholangiodram before and after the stent or drain placementClosure rates as high as 82%.

  • Nasopancreatic DrainageIt is another endoscopic method in which naso pancreatic drain placed into pancreatic duct beyond the site of obstructionNP drain Facilitate drainage of duct and fistula and thus help in closure of fistulaNP Drain should kept in situ for a week followed by endoprothesisAdvantage: Can do repeated pancreatogram to confirm the fistula closure without need for repeated ERCPDisadvantage: patient discomfort due to nasal tube and the necessity for continued nursing care

  • Surgical management of PPFIndication

    Failure of medical / Endoscopic ManagementObstruction of pancreatic duct that cannot be managed endoscopicallySymptomatic fit patient.Aim of Surgery

    To decompress the obstructed duct with or without excision of involved part of the obstructed pancreaseType of Surgery

    Cystogastrostomy / CystojejunostomyMid / Distal pancreatomy with pancreatico - jejunotomy

  • ConclusionPPF is difficult to diagnose and at times difficult to treatRecurrent pleural effusions with coexisting history of pancreatitis or alcohol abuse one should suspect PPFPulmonary symptoms are predominantEarly pleural fluid amylase testing will avoid delayed diagnosisInitial line of treatment: drainage of the effusion+ the inhibition of pancreatic secretions with octreotide and possibly ERCP plus stenting of the pancreatic duct.Surgery of pancreas is generally considered to be appropriate when medical measures fail

  • Referances Norman Oneil Machado, Pancreaticopleural Fistula: Revisited,Diagnostic and Therapeutic Endoscopy, vol. 2012, Article ID 815476, 5 pages, 2012. doi:10.1155/2012/815476JOP. Journal of the Pancreas - http://www.serena.unina.it/index.php/jop - Vol. 16 No. 1 Jan 2015. [ISSN 1590-8577]