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  • • History of chronic pancreatitis, recurrent acute pancreatitis, or pancreatic trauma

    • ERCP demonstrating disruption of pancreatic duct

    • Chemical analysis of ascites or pleural fluid demonstrating elevated amylase level

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Epidemiology

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  • • Pancreatic ascites or pleural effusion consists of accumulated pancreatic fluid in the abdomen or chest, originating from a pancreatic fistula, without peritonitis or severe pain

    • Most often due to chronic leakage of a pseudocyst; a few cases are due to disruption of a pancreatic duct (trauma)

    • The principal causative factors are alcoholic pancreatitis in adults and traumatic pancreatitis in children

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Symptoms and Signs

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  • • Marked weight loss

    • Abdominal distention (ascites)

    • Respiratory difficulty (effusion)

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Laboratory Findings

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  • • The fluid ranges in appearance from straw-colored to blood-tinged; contains elevated protein (> 2.9 g/dL) and amylase levels (usually > 3000 IU/dL)

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Imaging Findings

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  • ERCP: Demonstrates the point of fluid leak

    CT scan

    • -Small leaks not detected by ERCP may be imaged by CT scan performed immediately after ERCP while contrast media is still in the pancreatic duct

      -Associated pseudocysts can also be imaged by CT scan

    US: Allows monitoring of treatment

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  • • Once this condition is suspected, definitive diagnosis is based on chemical analysis of the ascitic fluid and ERCP

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Rule Out

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  • • Ascites from underlying hepatic disease

    • Pleural effusion from underlying pulmonary disease

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  • • Aspiration of fluid (chest or abdomen) and analysis for amylase concentration

    • ERCP

    • CT scan (if ERCP fails to identify source or if associated with pseudocyst)

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When to Admit

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  • • Respiratory difficulty

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  • • Drain fluid and chest tube (effusion); no oral intake, total parenteral nutrition, somatostatin

    • Surgery: Internal drainage

    • Endoscopic stenting of the pancreatic duct and may be successful

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Surgery

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Indications

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  • • No improvement after 2-3 weeks of medical treatment

    • Recurrence after removal of chest tube

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Medications

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  • • Somatostatin

    • Total parenteral nutrition

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Treatment Monitoring

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  • • US or CT scan to assess fluid accumulation

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Prognosis

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  • • Excellent with therapy

    • The death rate is low in patients treated before debilitation becomes severe

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References

Kaman L et al. Internal pancreatic fistulas with pancreatic ascites and pancreatic pleural effusions: recognition and management. Aust N Z J Surg. 2001;71:221.  [PubMed: 11355730]

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