Pleural effusion with rapid refill: A diagnostic dilemma-series of five cases

Abstract

Background: A rare complication of acute or chronic pancreatitis is the formation of a mediastinal pancreatic pseudocyst (MPP). Inflammatory injury causes pancreatic ductal disruption leading to leakage of amylase rich pancreatic secretions along the paths of minimum resistance. Thoracopancreatic fistulae are caused by the posterior disruptions while anterior disruptions can cause pancreatic ascites. Patients of pancreatitis can present with symptoms like chest pain, respiratory distress, dysphagia and in extreme cases with pericardial effusion and tamponade. High index of suspicion is needed in diagnosing this condition. Here, we report the imaging characteristics of five such cases. Our results revealed three features in common: (i) extension of pancreatic pseudocyst into the mediastinum; (ii) rapid refill of pleural effusions; and (iii) imaging findings consistent with pancreatitis. Aims: 1) To evaluate the cause of rapid refill of pleural effusion in cases of acute or chronic pancreatitis with pseudocysts. 2) To evaluate the mediastinal extension of the pseudocyst.Materials and Methods: Patients with rapid refill of pleural effusion were sent to the department of surgery and subsequently to radiology for further evaluation. Chest radiographs, diagnostic and therapeutic tap, abdominal ultrasonography, barium swallow and contrast enhanced CT scans of thorax and abdomen were done. Result: All our five patients of pancreatitis with rapid refill of pleural collection were found to have mediastinal extension of the pancreatic pseudocyst with pancreatico-pleural fistula.Conclusion: Mediastinal extension of the pancreatic pseudocyst with pancreatico-pleural fistula is a rare complication following acute or chronic pancreatitis. Detailed radiological investigations are a useful adjunct to surgical management.