Pancreaticomediastinal fistula as a rare cause of recurrent pleural effusions

A 45-year-old male with chronic alcoholism was transferred to our hospital with progressive dyspnoea, bilateral pleural effusions and ascites. Serum concentrations of lipase and CRP were increased. Pleural effusions recurred despite repeated thoracentesis, antibiotic therapy and total parenteral nutrition. A CT scan of chest and abdomen showed a lipomatous pancreas without signs of necrosis. Endosonography (EUS) demonstrated as signs of chronic pancreatitis an increased lobularity of the parenchyma without calcifications and two small cystic lesions in the pancreatic head. The pleural fluid lipase levels were markedly increased compared to a low lipase concentration in ascites. As an explanation for the pleural effusions ERCP showed a retroperitoneal fistula in the head/body region into the mediastinum and a stenosis of the pancreatic duct in the pancreatic head. For the ascites an inflammatory pathogenesis due to the exacerbation of chronic pancreatitis had to be assumed because the analysis showed an exudate with leukocytosis. After papillotomy via the pancreatic duct a 10 French wide 9 cm long stent was inserted into the pancreatic duct bridging the pancreatic fistula. Within 10 days pleural effusions had completely receded. After three weeks pancreaticography showed a total regression of the fistula and the stent was exchanged. After 6 weeks the pancreatic stent was removed with a lasting remission of the pleural effusions.