GI Grand Rounds

1
GI Grand Rounds

• Yoshi Makino
• July 25, 2003

2
Clinical Case

• CC shortness-of-breath with hemoptysis x 1 week
• HPI J.O. is a 48 yo HM with PMH sig. for
  pancreatitis 2 to EtOH, presenting to LACUSC on
  6/22/02 with the above complaint. Pt also noted
  ()pleuritic chest pain, ()weight loss (40 lbs/5
  months), ()back pain near right scapula.(-)abd
  pain (-)fever/chills, (-)N/V, (-)melena/ BRBPR

3
History

• PMH
• pancreas problems (2000, dxed in Mexico)
• pancreatic pseudocysts (2002, by CT at Kaiser,
  Baldwin Park)
• PSH none
• SH
• Born in Mexico, in US for 3 years
• EtOH h/o heavy EtOH abuse (unquantifiable
  amounts of hard liquor/d), quit 3 years ago when
  told of pancreatic disease
• Denies tobacco/illicit drug use
• FH non-contributory

4
Physical Exam

• Vitals T 99.0 P 125 R 40 BP 125/67
• General AO x 4 in severe respiratory distress
• HEENT PERRLA, EOMi, MMM
• Cardiac sinus tachy, without murmurs/rubs
• Chest diminished BS bilaterally, RgtL
• Abd soft, NT, ND, ()BS, (-)ascites, without
  papable liver/speen
• Ext without clubbing/cyanosis/edema

5
Labs
6
Chest X-ray
7
Differential Diagnosis

• Transudates
• Congestive heart failure
• Cirrhosis
• Atelectasis
• Nephrotic syndrome
• Peritoneal dialysis
• Myxedema
• Constrictive pericarditis

• Exudates
• Malignancy
• Pulmonary embolism
• Collagen vascular disease
• Tuberculosis
• Asbestos-related illness
• Pancreatitis, pseudocyst
• Trauma
• Postcardiac injury syndrome
• Esophageal perforation
• Radiation pleuritis
• Drug-induced reactions
• Chylothorax
• Meig's syndrome (ovarian fibromas )

8
Next Tests?
9
Hospital Course

• Thoracentesis was performed in the ER, with 1200
  cc removed, revealing
• Amylase 85,345
• Protein 3.1
• Glucose 121
• LDH 473
• Nuc. Cells 97, Gram Stain(-)

10
Hospital Course

• Pt remained severely dyspnic, and was intubated
  and admitted to the ICU on 6/22/03. Pt became
  hypotensive, requiring pressors.
• CT Chest/Abd/Pelvis (6/22/03) massive R pleural
  effusion, R lung collapse, partial L lung
  collapse, small fluid collection posterior to
  intra and subhepatic IVC, possibly an extension
  from a pancreatic pseudocyst although connection
  to pancreas not demonstrated

11
Hospital Course

• Based on history and pleural fluid analysis, a
  diagnosis of pancreaticopleural fistula was made
• Pt was placed on strict NPO and bowel rest
• Bilateral chest tubes and a R pig tail catheter
  were placed
• Octreotide drip was started on 6/24/03 and given
  for a total of 7 days

12
Hospital Course

• CT Chest/Abd/Pelvis (6/30/03) slight interval
  increase in retroperitoneal fluid collection,
  posterior to intrahepatic IVC, presumably
  representing a pancreatic pseudocyst
• MRCP (7/3/03) no MR evidence of
  choledocholithiasis with normal caliber and
  contour of common bile duct (? leak seen)
• Pt has since clinically improved
• 7/1/03 extubated and off pressors
• 7/7/03 L chest tube d/ced
• 7/11/03 R chest tube d/ced
• 7/16/03 R pig-tail d/ced

13
Pleural Fluid Amylase
14
Pancreaticopleural Fistulas
15
Pancreatits and Pleural Effusions

• Acute Pancreatits
• small pleural effusions occur in 3 to 17 of
  patients
• arise from chemically mediated inflammation of
  the diaphragm and pleura
• Chronic pancreatitis
• pancreaticopleural fistulas are rare complication
  of chronic pancreatitis (estimated incidence of
  0.4, increases to 3 with pseudocysts)
• effusion is typically severe, and may present
  bilaterally
• Rockey DC. Medicine 1990.

16
Presenting Symptoms

• Abdominal pain (51)
• Dyspnea (43)
• Weight loss (37)
• Chest pain (34)
• Dysphagia (26)
• Nausea and vomiting (23)
• Fever (11)
• Back pain (11)
• Beauchamp RD. Surgery. 1989.

17
Pathophysiology

• Chronic inflammation and obstruction of the main
  pancreatic duct results in posterior rupture with
  or without the formation of a posterior
  pseudocyst
• Pancreatic fluid leaks into the retroperitoneum
• The fluid then extends caudally either via the
  esophageal or aortic hiatus or directly through
  the diaphragm, and can form
• pancreaticopleural fistula
• mediastinal pseudocyst
• pancreaticobronchial fistula
• pancreaticopericardial fistula

18
Diagnosis

• History
• History of pancreatitis with severe pleural
  effusion
• Pleural chemistry
• Amylase gt10,000 IU/L
• Protein gt 3 gm/dL
• Additional imaging
• ERCP
• CT Abdomen

19
Computer Assisted Tomography

• Recommended for demonstrating
• pancreatic parenchymal atrophy
• dilatation of the pancreatic ducts,
  calcifications, and pseudocysts
• evaluation of mediastinal fluid collections, and
  their relationship to other stuctures
• occasionally, may reveal the fistula itself
• Fulcher, AS. Journal of Computer Assisted
  Tomography. March/April 1999.

20

• Bilateral pleural fluid collections P and a
  mediastinal pseudocyst PC, fistula with a low
  attenuation center and a higher attenuation rim
  (arrows)
• Fulcher. J Comput Assist Tomogr. March/April 1999.

21
MRCP

• Heavily T2-weighted images result in high signal
  intensity of static or slowly flowing fluids
• Strength
• non-invasive, no contrast agent used
• ability to visualize pancreatic ductal anatomy
  beyond points of ductal obstruction
• multiplanar reconstruction allows for better
  visualization of typically oliquely oriented
  fistulas
• Materne R. Chest. March 2000.

22

• Fulcher. J Comput Assist Tomogr. March/April
  1999.

23
ERCP

• Study of choice for
• depicting the anatomy of thoracopancreatic
  fistulas and the pancreatic duct
• planning for optimal surgical approach
• Weaknesses
• may not reveal all fistulas in two case series
  missed, 2 of 6 cases (Kaman) and 2 of 6 cases
  (Fulcher AS)
• invasive procedure with risk of pancreatitis

24

• ERCP demonstrating a posterior pancreatic
  pseudocyst C with a fistula track F extending
  to the right pleural cavity. The pancreatic duct
  PD is dilated, irregular, and tortuous, in
  keeping with chronic pancreatitis.
• Bishop J Pediatr Gastroenterol Nutr. January
  2003.

25
Imaging Modalities Compared

• Fulcher, AS. et al. Thoracopancreatic Fistula
  Clinical and Imaging Findings. Journal of
  Computer Assisted Tomography. 23(2)181-187,
  March/April 1999.

26
Treatment

• Medical therapy
• Total gut rest
• Parenteral nutrition
• Drainage of the pleural space,
• repeated thoracentesis
• thoracostomy tube
• Addition of somatostatin/octreotide has increased
  the success rate of medical therapy to as much as
  40
• Rockey DC. Medicine 1990.

27
Somatostatin and Octreotide

• Somatostatin
• inhibits secretin- and cholecystokinin-induced
  exocrine pancreatic secretion
• effective in reducing the volume of both
  bicarbonate and protein secretion from external
  pancreatic fistulas
• Octreotide
• synthetic analog of somatostatin
• has a longer half-life
• Considered standard therapy for
  pancreatico-pleural fistulas and all pancreatic
  fistulous disease
• Rockey DC. Medicine 1990.

28
Endoscopic Therapy

• Endoscopic placement of pancreatic stents has
  been performed with some relative success for the
  treatment of pancreaticopleural fistula
• Reestablishes the normal flow of pancreatic
  secretions, thereby decreasing the pressure in
  the fistulous tract and allowing its closure
• A meta-analysis of 5 studies comprising 261
  patients suggest that stent placement was
  successful in over 80 of patients

29
Stent Therapy in Chronic Pancreatitis

• Venu J Clin Gastroenterol, Volume 34(5).May/June
  2002.560-568

30
Indications for Surgery

• Persistence of the effusion despite medical
  therapy
• Bacterial infection of the pseudocyst and/or
  pleural fluid
• Recurrence of the effusion after reintroduction
  of oral intake
• Approximately 60 of patient with
  pancreatico-pleural fistulas will require surgery
• Burgess NA. Hepato-Pancreatico-Biliary Surg 1992.

31
Surgical Therapy

• Prior to somatostatin, surgical correction was
  the treatment of choice for pancreaticopleural
  fistula
• In a series of 30 patients with pancreatic
  pseudocyst of the mediastinum reported by
  Johnston (Ann Thoracic Surg 1986)
• death resulted in 1 of 26 patients managed
  surgically
• versus, 4 of 4 patients managed medically
• Today, operative fistula closure rates as high as
  80 to 95, with mortality as low as 5, have been
  reported

32
Surgical Therapy

• Definition of the pancreatic ductal anatomy with
  preoperative ERCP is recommended
• If ductal disruption is distal, and proximal duct
  is normal, distal pancreatic resection is
  performed
• If ductal pathology is proximal, it is drained
  into a Roux-en-Y loop of jejunum

33
Summary

• Pancreaticopleural fistula should be suspected in
  a patient with a history of alcoholism and a
  chronic pleural effusion
• Exudative pleural effusion with markedly elevated
  pleural fluid amylase is pathognomonic for this
  condition
• ERCP is the still the diagnostic standard for
  ductal pathology, but MRCP is becoming an
  increasingly useful diagnostic tool
• Standard medical therapy includes intravenous
  octreotide, bowel/gut rest, and total parenteral
  nutrition