Dual Internal Pancreatic Fistulae Complicating Chronic Pancreatitis
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SCIENTIFIC LETTER
Dual Internal Pancreatic Fistulae Complicating Chronic Pancreatitis R. Ganesh 1 & Malathi Sathiyasekeran 2 & N. Suresh 1 & G. Padmapriya 3 & Nataraj Palaniappan 1,3 & Karthik Narayanan R 1,3 Received: 9 July 2020 / Accepted: 7 October 2020 # Dr. K C Chaudhuri Foundation 2020
To the Editor: A 4-y-old girl diagnosed as chronic calcific pancreatitis (CCP) presented with sudden onset of breathlessness for 1 wk. She was tachypneic with reduced air entry-right chest. Other systems examination was normal. Complete blood count (CBC), blood sugar, C-reactive protein (CRP) were normal. Chest X-ray showed massive right pleural effusion (Fig. 1). Serum amylase was 1036 U/L and lipase was 1262 U/L. Therapeutic thoracocentesis of 900 ml of hemorrhagic fluid was done in 2 sittings over 48 h. Pleural fluid amylase and lipase were 56,450 U/L, 41800 U/L respectively, suggesting pancreatico pleural fistula (PPF). Magnetic resonance cholangiopancreatography (MRCP) and Endoscopic retrograde cholangiopancreatography (ERCP) could not delineate the PPF but confirmed an intraductal calculus at the junction of pancreatic head and neck. A selective pancreatic sphincterotomy was done and few calcareous deposits removed, however guide wire could not be negotiated beyond the calculus. Following sphincterotomy and thoracic drainage, pleural effusion decreased in 3 wk. She was managed with pigtail drainage, proton pump inhibitors, octreotide and nasogastric semi elemental peptide based formula. At discharge chest skiagram was normal. Three weeks later, she presented with pallor and severe pain in epigastrium and left hypochondrium (Hb: 7.1 g/dl). Serum amylase was 293 U/L and lipase was 460 U/L. CECT abdomen revealed peripancreatic necrosis with hemorrhagic collection (5 × 4 × 4 cm) at the gastro splenic region (Fig. 2) with ascites. CT
guided aspiration and pigtail stent was placed which was retained for 3 wk. The aspirated hemorrhagic fluid revealed amylase 2,38,000 U/L suggesting pancreatic ascites (PA). She was given packed red blood cells (PRBC) transfusion and other supportive measures continued following which PA resolved in 3 wk. Pancreatic fistula (PF) is a very rare complication of chronic pancreatitis (CP) [1]. Chronic inflammation of pancreas or increased intraductal pressure secondary to stones leads to pancreatic ductal disruption either anteriorly into the peritoneal cavity resulting in PA [2] or posteriorly when the fluid traverses superiorly into pleural cavity resulting in PPF [3]. Pleural fluid amylase >1000 U/L is diagnostic of PPF [4]. This child with CCP had a very rare complication of dual internal PF with a time lag between the two, indicating they were separate events. The management of PF is primarily conservative [5]. Endotherapy with pancreatic stenting is a good option and surgery is indicated only when there is failure of endotherapy [5]. Our patient responded to the image guided aspiration and endotherapy. Endotherapy/surgery has been planned if the symptoms recur.
* R. Ganesh ganeped79@rediffm
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