(Chest. 2000;117:912-914.)
© 2000
American College of Chest Physicians
Pancreaticopleural Fistula*
Diagnosis With Magnetic Resonance Pancreatography
Roland Materne, MD;
Patrick Vranckx, MD;
Carl Pauls, MD;
Emmanuel E. Coche, MD;
Pierre Deprez, MD and
Bernard E. Van Beers, MD, PhD
*
From the Departments of Radiology (Drs. Materne, Coche, and Van Beers) and Medicine (Dr. Deprez), Université Catholique de Louvain, St-Luc University Hospital, Avenue Hippocrate 10, B-1200 Brussels, Belgium; and the Department of Radiology (Drs. Vranckx and Pauls), St-Pierre Hospital, Avenue Reine Fabiola 13, B-1340 Ottignies, Belgium.
Correspondence to: Roland Materne, MD, Department of Radiology, St-Luc University Hospital, Avenue Hippocrate, 10 B-1200 Brussels, Belgium; e-mail: materne{at}rdgn.ucl.ac.be
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Abstract
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Pancreaticopleural fistula secondary to chronic pancreatitis is a
rare cause of recurrent pleural effusion. The demonstration of the
fistula with endoscopic retrograde pancreatography and CT is invasive
or limited. We report in two patients the use of magnetic resonance
pancreatography as a noninvasive alternative to endoscopic retrograde
pancreatography for the diagnosis of pancreaticopleural
fistula.
Key Words: diseases • fistula • MRI • pancreas • pancreaticopleural
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Introduction
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Pancreaticopleural
fistula is a rare complication of chronic pancreatitis.1
It results from posterior disruption of the pancreatic duct into the
retroperitoneal space, leading to the formation of a fistulous tract
between the pancreas and the pleural cavity through the aortic or
esophageal hiatus. Clinical presentation is often misleading, as
respiratory rather than abdominal symptoms predominate. Markedly
elevated pleural fluid amylase level is the most important laboratory
finding. The pancreatic fistula can be demonstrated by endoscopic
retrograde pancreatography. However, selective duct cannulation is
invasive, and the entire anatomy of the fistula will not always be
delineated.2
3
Therefore, there is a need for an accurate
and noninvasive procedure that could substitute for diagnostic
endoscopic retrograde pancreatography. Visualization of
pancreaticopleural fistula in chronic pancreatitis has been reported
with CT,2
4
5
but the sensitivity of this imaging method
for the demonstration of fistulas is low.2
3
We report two cases of pancreaticopleural fistula demonstrated by
magnetic resonance (MR) pancreatography.
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Case Reports
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Case 1
A 50-year-old man with a history of chronic alcoholic
pancreatitis complained of cough, dyspnea, and left-sided chest pain.
Physical examination revealed a left-sided pleural effusion that was
confirmed by chest radiography. Pleural fluid amylase was 30,750 IU/L;
total protein, 4.5 g/dL; glucose, 137 mg/dL; and WBC count, 86
cells/µL. CT of the chest and abdomen showed the left-sided pleural
effusion and characteristic features of chronic pancreatitis, including
parenchymal atrophy with numerous calcifications, and a caudal
pseudocyst. Endoscopic retrograde pancreatography demonstrated
dilatation of the main pancreatic duct with intraductal calcifications,
and leak of contrast material from the tail of the pancreas toward the
left pleural cavity.
Having failed to respond to medical treatment including total
parenteral nutrition and somatostatin infusion, the patient was
transferred to our institution for surgical therapy. MRI was performed
for preoperative assessment of the pancreatic anatomy. First,
conventional T1- and T2-weighted images of the upper abdomen were
obtained. Next, MR pancreatography was performed with a breath-hold,
single-shot, fast spin-echo sequence using two acquisition techniques:
sequential single-slice acquisition with thick slices (effective echo
time, 871 ms; acquisition time, 2 s; slice thickness, 20 mm) and
multislice acquisition with thin slices (effective echo-time, 94 ms;
acquisition time, 30 s; slice thickness, 3 mm). Single-slice
acquisition was obtained in the coronal and coronal oblique planes, and
multislice acquisition in the coronal and transverse planes. Coronal
projectional images were constructed with the maximal intensity
projection algorithm. In addition to features of chronic pancreatitis,
MR pancreatography demonstrated the pancreaticopleural fistula that
extended from the tail of the pancreas to the left pleural cavity (Fig 1
). The presence of the pancreaticopleural fistula was confirmed at
surgery, and the patient underwent distal pancreatectomy and
longitudinal pancreaticojejunostomy.
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Figure 1.. A 50-year-old man with chronic pancreatitis.
Coronal projectional MR pancreatographic image shows dilatation of the
main pancreatic duct with intraductal calcifications (arrowheads), and
pancreaticopleural fistula (arrow) that extends to the left
pleural cavity. GB = gallbladder; St = stomach;
LPE = left-sided pleural effusion; D = duodenum.
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Case 2
A 32-year-old man with a history of chronic alcoholic
pancreatitis was admitted for progressive dyspnea. Physical examination
was suggestive of a large left-sided pleural effusion that was
confirmed by chest radiography. Pleural fluid amylase measurement was
10,800 IU/L; total protein, 4.3 g/dL; glucose, 43 mg/dL; and WBC count,
6,880 cells/µL. CT of the chest and abdomen showed the left-sided
pleural effusion and features of chronic pancreatitis, including
parenchymal atrophy with multiple calcifications and dilatation of the
main pancreatic duct. Furthermore, a subtle infiltration of the
retroperitoneal fat between the pancreas and the crus of the left
hemidiaphragm was considered as a possible sign of a fistulous tract
between the pancreas and the left pleural cavity. Endoscopic retrograde
pancreatography demonstrated a stenosis at the distal part of the main
pancreatic duct and a 4-mm obstructive stone inside the duct.
Cannulation of the minor papilla resulted in opacification of a dilated
main pancreatic duct proximal to the obstructive stone. No fistula
could be demonstrated.
MRI was performed, and conventional T1- and T2-weighted images of
the upper abdomen were obtained. Next, MR pancreatography was performed
using sequential single-slice acquisitions (effective echo-time, 1,100
ms; acquisition time, 5 s; slice thickness, 50 mm) in the coronal
plane, and multislice acquisitions (effective echo-time, 90 ms;
acquisition time, 11 s; slice thickness, 4 mm) in the transverse
and coronal planes. MR pancreatography demonstrated a
pancreaticopleural fistula arising at the level of the head of the
pancreas toward the left pleural cavity (Fig 2 ). Endoscopic retrograde pancreatography was repeated and the fistula
was confirmed. After sphincterotomy of the minor papilla, a pancreatic
stent was placed and the patient received somatostatin, 200 µg/h. The
evolution was uneventful with complete regression of the pleural
effusion.
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Figure 2.. A 32-year-old man with chronic pancreatitis.
Coronal MR pancreatographic image shows pancreaticopleural fistula
(arrow) arising at the level of the head of the pancreas (arrowheads).
See Figure 1
legend for abbreviations.
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Discussion
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Pleuropulmonary complications are relatively frequent in
patients with acute pancreatitis. Pleural effusions are reported to
occur in 4 to 17% of patients. The effusion is commonly small,
transient, and left sided. In contrast, pleural effusions are less
common in patients with chronic pancreatitis. The effusion is often
large and recurrent, arising from a fistulous tract between the
pancreas and the pleural cavity, with or without pseudocyst formation.
It usually predominates on the left side, but may be right sided or
bilateral. The pleural fluid is typically an exudate with very high
amylase content. The causes of an elevated amylase level in pleural
fluid include acute pancreatitis, esophageal perforation, and various
types of tumors such as lung carcinoma and female genital tract
carcinoma. Clinical presentation, radiographic studies, and
determination of the amylase isoenzyme levels usually confirm the
diagnosis.
Endoscopic retrograde pancreatography and CT have been used
for the diagnosis of pancreaticopleural fistula.1
2
4
5
Endoscopic retrograde pancreatography is very useful for imaging the
pancreatic ductal anatomy, and can demonstrate the fistulous tract that
extends to the pleural cavity. CT is recommended to show pancreatic
parenchymal atrophy, in addition to dilatation of the pancreatic ducts,
calcifications, and pseudocysts. Furthermore, the fistula can sometimes
be revealed. However, endoscopic retrograde pancreatography and
especially CT may fail to demonstrate the entire anatomy of the
pancreaticopleural fistula.2
3
In addition, endoscopic
retrograde pancreatography is an invasive procedure with a small but
substantial complication rate, including acute pancreatitis, sepsis,
and bleeding.
MR pancreatography is a noninvasive imaging method to
assess pancreatic diseases.6
MR pancreatography is based
on the acquisition of heavily T2-weighted images, which result in high
signal intensity of static or slowly flowing fluids. Chronic
pancreatitis may be consistently evaluated with this imaging method. MR
pancreatography can depict parenchymal and ductal structural changes,
but also extrapancreatic complications, including pancreaticopleural
fistula as shown in our cases. MR pancreatography provides an overview
of the fistulous tract, which appears as a high-signal-intensity
structure. No contrast material is injected, and therefore there is no
risk of infection. Site of fistulization and anatomic relationships are
precisely defined, suggesting that diagnostic endoscopic retrograde
pancreatography should be performed only in confusing cases.
In conclusion, MR pancreatography can show pancreaticopleural
fistulas, and may be a noninvasive alternative to diagnostic endoscopic
retrograde pancreatography.
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Footnotes
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Abbreviation: MR = magnetic resonance
Received for publication June 16, 1999.
Accepted for publication September 10, 1999.
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References
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Wakefield, S, Tutty, B, Britton, J (1996) Pancreaticopleural fistula: a rare complication of chronic pancreatitis. Postgrad Med J 72,115-116[Abstract]
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McCarthy, S, Pellegrini, CA, Moss, AA, et al (1984) Pleuropancreatic fistula: endoscopic retrograde cholangiopancreatography and computed tomography. AJR Am J Roentgenol 142,1151-1154[Abstract/Free Full Text]
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Abstract
Introduction
