Pancreatic Ascites & Pancreatic Pleural Effusion

• • 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

Epidemiology

• • 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

Symptoms and Signs

• • Marked weight loss

  • Abdominal distention (ascites)

  • Respiratory difficulty (effusion)

Laboratory Findings

• • 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)

Imaging Findings

• • 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

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

Rule Out

• • Ascites from underlying hepatic disease

  • Pleural effusion from underlying pulmonary disease

• • 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)

When to Admit

• • Respiratory difficulty

• • 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

Surgery

Indications

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

  • Recurrence after removal of chest tube

Medications

• • Somatostatin

  • Total parenteral nutrition

Treatment Monitoring

• • US or CT scan to assess fluid accumulation

Prognosis

• • Excellent with therapy

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

References