Pancreaticopleural fistula

1. IMHC
Brian Locke, PGY1
Sept 23, 2016
‘AM’ Report

2. CXR

3. CT Chest / Abd

4. CXR

5. CXR

6. Pleural Fluid Analysis
 Transudate (Inc. PCWP or Dec. Oncotic) = Systemic
 Exudate (Vascular Permeability, etc) = Local
 Lytes Criteria (5, 6, 7 10ths rule)
 Pleural protein greater than 5 / 10 serum
 Pleural LDH greater than 6 / 10 serum
 Pleural LDH greater than .66 = 7 / 10 ULN serum
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 Add cholesterol greater 3 / 10 serum (Spec. Ex. 83->97%)

7. Pancreaticopleural Fistula
 Amylase Rich Pleural Effusion (over 200 IU/L)
 Pancreatic
 Acute = mildly elevated fluid amylase
 Pseudocyst w/ fistula = massively elevated
 Cancer = MOST COMMON (Amylase over 600 IU/L)
 Esophageal (recent instrumentation, Boerhaave’s)

8. Pancreaticopleural Fistula
 Ruling out lung cancer
 Diagnostic yield of pleural fluid analysis = ~50%
 If negative, repeat pleural fluid analysis
 If negative, VATS w/ pleural biopsy (7-27% yield)
 Combined: sensitivity = 94-100%

9. Pancreaticopleural Fistula
 Management
 40-60% spontaneous resolution in 6w
 Octreotide lowers fistula output, but same rate of closure
 Enteral feeds as tolerated
 Stenting if possible (based on anatomy)
 Resolution in 55-90% of cases
 Surgery as last resort