Users Online: 3914
Home Print this page Email this page
Home About us Editorial board Search Browse articles Submit article Ahead of Print Instructions Subscribe Contacts Login 


 
Previous article Browse articles Next article 
CASE REPORT
Adv Biomed Res 2016,  5:42

Hemorrhagic pleural effusion due to pseudo-pancreatic cyst


1 Department of TB and Respiratory Medicine, Pt. B.D. Sharma PGIMS, Rohtak, Haryana, India
2 Department of Community Medicine, Pt. B.D. Sharma PGIMS, Rohtak, Haryana, India

Date of Submission20-May-2013
Date of Acceptance04-Jul-2015
Date of Web Publication16-Mar-2016

Correspondence Address:
Dr. Ruchi Sachdeva
Department of TB and Respiratory Medicine, Pt. B.D. Sharma PGIMS, Rohtak - 124 001, Haryana
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2277-9175.178789

Rights and Permissions
  Abstract 

Hemorrhagic pleural effusion is a common clinical entity still diagnosis is often missed. An unusual and often over-looked cause of pleural effusion is an intra-abdominal process including complication arising due to pancreatitis. We report a rare case of massive left sided hemorrhagic pleural effusion in a patient due to pancreatic pathology.

Keywords: Abdomen, alcohol, bleeding, chest pain, fistula, neoplasm, pancreas, trauma


How to cite this article:
Sachdeva R, Sachdeva S. Hemorrhagic pleural effusion due to pseudo-pancreatic cyst. Adv Biomed Res 2016;5:42

How to cite this URL:
Sachdeva R, Sachdeva S. Hemorrhagic pleural effusion due to pseudo-pancreatic cyst. Adv Biomed Res [serial online] 2016 [cited 2019 Nov 16];5:42. Available from: http://www.advbiores.net/text.asp?2016/5/1/42/178789


  Introduction Top


Hemorrhagic pleural effusion is a common entity still definitive diagnosis is often missed. Trauma is the common cause presenting with hemorrhagic effusion, and other causes include intrathoracic neoplasm, bleeding diathesis, rupture due to pulmonary embolism, iatrogenic interventions, or tuberculosis.[1] Unfortunately, as many as 15–20% cases of all pleural effusion remain undiagnosed despite intensive efforts.[2] An unusual and over-looked cause of pleural effusion is an intra-abdominal entity, e.g., pancreatitis.[3] We report a rare case of massive left sided pleural effusion (hemothorax) in a patient due to pancreatic pathology.


  Case Report Top


A 50-year-old male, farmer by occupation, presented with chief complaints of left side chest pain, cough with mild expectorate, and abdominal pain since 5 months. Chest pain was initially sharp in character, increased with deep inspiration, non-radiating in nature with no relation to meals. Pain in abdomen was intermittent, dull aching, non-radiating, and not associated with posture or meals. Past history was not significant. The patient was alcohol drinker (100 ml [approximate], at least thrice a month since 15 years with higher intake on social occasions) and chronic smoker. Laboratory investigations are shown in [Table 1]; Montoux was negative. Chest X-ray showed left sided pleural effusion [Figure 1]. Ultrasound abdomen revealed - a cystic lesion of size 10.5 cm by 7 cm in relation to tail of pancreas (pseudo-pancreatic cyst) while liver, gall bladder, spleen, and kidneys were within the normal limits. Pleural fluid was hemorrhagic in nature and negative for acid fast bacilli. Pleural fluid cytology showed lymphocytes, neutrophils, numerous foamy macrophages, mesothelial cells, and few degenerated cells. Contrast-enhanced computed tomography (chest and abdomen) revealed a large cystic lesion involving tail of the pancreas. It extended beyond the confines of the pancreas over the left kidney, spleen, and left hemi-diaphragm into left pleural space. Massive left side pleural effusion was seen with collapse consolidation of underlying lung. No mediastinal lymphadenopathy was visible and right lung field appeared normal. The investigations led to the conclusion of pseudo-pancreatic cyst rupture into pleural space [Figure 2]. Magnetic resonance cholangiopancreatography (MRCP) was carried out for further confirmation [Figure 3]. Intercostals drainage [Figure 4] was done on left side in order to drain hemorrhagic fluid and patient was started on injection octreotide 100 μg s/c thrice a day for decreasing pancreatic secretions along with broad spectrum antibiotics. He was managed conservatively for 4 weeks with clinical improvement of chest condition and then taken up for surgery for drainage of cyst.
Table 1: Laboratory investigations

Click here to view
Figure 1: Chest X-ray showed left sided pleural effusion

Click here to view
Figure 2: Contrast-enhanced computed tomography (chest and abdomen) revealed cyst in the tail of pancreas and tract (L: Lung, Pl: Pleura, P: Pancreas, C: Cyst)

Click here to view
Figure 3: Magnetic resonance cholangiopancreatography image

Click here to view
Figure 4: Chest X-ray after inter-costal drainage

Click here to view



  Discussion Top


Hemothorax rarely occurs as a sole manifestation of pancreatitis.[1],[2],[3],[4],[5],[6] Most cases of hemorrhagic pleural effusion secondary to pancreatitis occur between the ages of 20 and 55, along with a risk factor of alcohol intake.[4],[5] The postulated pathogenic mechanisms for hemorrhagic effusions include trans-diaphragmatic transfer of fluid via lymphatics, diaphragmatic perforation of the pseudocyst and mediastinal extension.[1] Several studies demonstrated that a fistula connecting a pancreatic pseudocyst with pleural cavity was the plausible mechanism of pleural effusion.[6],[7] A pancreaticopleural fistula is a rare complication of pancreatitis with reported incidence of only 0.4–4.5%.[8] The cyst fistulizing and bleeding massively to cause hemothorax have been very rarely reported.

In our case, the patient presented with massive hemothorax on left side secondary to accidentally detected pseudocyst pancreas with very high amylase content in pleural fluid (normal range <150 IU/L). Pleural effusions due to pancreatic diseases are mostly reactive with slightly elevated amylase levels. In most cases, the pleural effusion occurs concomitantly with signs and symptoms of pancreatitis but may occur even after the acute abdominal symptoms have subsided. Considerable diagnostic problems may be encountered in cases in which the clinical picture is dominated by pleuropulmonary symptoms, and the pancreatic condition remains completely or partly hidden in the background.[9] The other causes of hemorrhagic effusions with an increased amylase include traumatic esophageal rupture, intrathoracic, and other neoplasm's.

Visualization of a pancreaticopleural fistula can be achieved using computed tomography, but overall sensitivity appears to be poor.[10] MRCP is the investigation of choice nowadays because of its noninvasive nature over endoscopic retrograde cholangiopancreatography and its ability to visualize beyond strictures.[11] Moreover, in chronic pancreatitis, it can depict parenchymal atrophy, ductal anatomy and small intrapancreatic or extrapancreatic pseudocysts, peripancreatic collections or pancreaticopleural fistula, if any. The mainstay of medical treatment include conservative management, that is, total parenteral nutrition, thoracocentesis and somatostatin, or analog; nearly 50% of patients managed this way respond to treatment.[12] In cases of failure, some authors advise pancreatic ductal stenting as the next line of management while cases of recurrence and failure are potential candidates for surgical interventions. Surgical procedures include pancreatic resection and drainage of the pseudocyst with or without enteropancreatic anastomosis.[8] Three different approaches for pancreatic pseudocysts drainage are available: Endoscopic (transpapillary or transmural), percutaneous catheter drainage, or open surgery. Until date, no controlled prospective studies have compared directly these approaches. About 80–95% have a satisfactory outcome from surgical intervention with reported mortality rate of 3%.[13] To conclude, lack of clinical suspicion along with inadequate investigative support could result in delay in diagnosis, sub-optimum management including poor prognosis.

Acknowledgement

Department of TB, Respiratory Medicine and Radio-diagnosis, Pt. B.D. Sharma, PGIMS, Rohtak - 124 001, India.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Raghu MB, Balasubramanian S, Balasubramanyam G. Hemorrhagic pleural effusion – Sole manifestation of pancreatitis. Indian J Pediatr 1992;59:767-9.  Back to cited text no. 1
[PUBMED]    
2.
Hirsch A, Ruffie P, Nebut M, Bignon J, Chrétien J. Pleural effusion: Laboratory tests in 300 cases. Thorax 1979;34:106-12.  Back to cited text no. 2
    
3.
Kaye MD. Pleuropulmonary complications of pancreatitis. Thorax 1968;23:297-306.  Back to cited text no. 3
[PUBMED]    
4.
Ramsdell CM, Muslow I. Recurrent hemorrhagic pleural effusion associated with relapsing pancreatitis. South Med J 1973;66:1016-8.  Back to cited text no. 4
[PUBMED]    
5.
Siwczynski H. Chronic pleural effusion from the pancreas. Wiad Lek 1998;51:190-5.  Back to cited text no. 5
    
6.
Imai Y, Taniguchi M, Tagawa K, Toda N, Tanzawa Y, Okamoto M, et al. A case of chronic pancreatitis complicated by massive pericardial and right pleural effusion. Gastroenterol Jpn 1993;28:734-8.  Back to cited text no. 6
    
7.
Dewan NA, Kinney WW, O'Donohue WJ Jr. Chronic massive pancreatic pleural effusion. Chest 1984;85:497-501.  Back to cited text no. 7
    
8.
Dhebri AR, Ferran N. Nonsurgical management of pancreaticopleural fistula. JOP 2005;6:152-61.  Back to cited text no. 8
    
9.
Svane S. Recurrent, hemorrhagic pleural effusion and eosinophilia accompanying pancreatitis. Acta Chir Scand 1966;131:352-6.  Back to cited text no. 9
[PUBMED]    
10.
Megibow AJ, Lavelle MT, Rofsky NM. MR imaging of the pancreas. Surg Clin North Am 2001;81:307-20, ix-x.  Back to cited text no. 10
    
11.
Materne R, Vranckx P, Pauls C, Coche EE, Deprez P, Van Beers BE. Pancreaticopleural fistula: Diagnosis with magnetic resonance pancreatography. Chest 2000;117:912-4.  Back to cited text no. 11
    
12.
Rockey DC, Cello JP. Pancreaticopleural fistula. Report of 7 patients and review of the literature. Medicine (Baltimore) 1990;69:332-44.  Back to cited text no. 12
    
13.
Martin FM, Rossi RL, Munson JL, ReMine SG, Braasch JW. Management of pancreatic fistulas. Arch Surg 1989;124:571-3.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1]



 

Top
Previous article  Next article
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Case Report
Discussion
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed1109    
    Printed21    
    Emailed0    
    PDF Downloaded116    
    Comments [Add]    

Recommend this journal