A 54-year-old man comes to the emergency department due to shortness of breath. Over the past 2 weeks he has had progressively labored breathing that now occurs even at rest. He has had no chest pain, cough, fevers, night sweats, nausea, vomiting, or weight changes. The patient does note frequent "attacks" of epigastric pain for the past 10 years, which occur twice a month and last a few days at a time. Medical history is significant for alcohol withdrawal seizures; the patient has consumed 7 or 8 beers a day for the past 20 years. Temperature is 37.7 C (98.8 F), heart rate is 95/min, and respirations are 23/min; oxygen saturation is 92% on 4 L oxygen by nasal cannula. Physical examination shows decreased breath sounds on the left side along with dullness to percussion. The abdomen is tender to palpation in the epigastrium without rebound or guarding. Extremities are warm and well perfused without edema or clubbing. Chest x-ray reveals a large, left-sided pleural effusion. Thoracentesis results in removal of 1.5 L of fluid. A sample is sent for analysis, revealing the following: What is the most likely diagnosis in this patient?

Question

A 54-year-old man comes to the emergency department due to shortness of breath.  Over the past 2 weeks he has had progressively labored breathing that now occurs even at rest.  He has had no chest pain, cough, fevers, night sweats, nausea, vomiting, or weight changes.  The patient does note frequent "attacks" of epigastric pain for the past 10 years, which occur twice a month and last a few days at a time.  Medical history is significant for alcohol withdrawal seizures; the patient has consumed 7 or 8 beers a day for the past 20 years.  Temperature is 37.7 C (98.8 F), heart rate is 95/min, and respirations are 23/min; oxygen saturation is 92% on 4 L oxygen by nasal cannula.  Physical examination shows decreased breath sounds on the left side along with dullness to percussion.  The abdomen is tender to palpation in the epigastrium without rebound or guarding.  Extremities are warm and well perfused without edema or clubbing.  Chest x-ray reveals a large, left-sided pleural effusion.  Thoracentesis results in removal of 1.5 L of fluid.  A sample is sent for analysis, revealing the following:  What is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d878_6b0f_bc81_f306e369869d_MD0003_00 This patient has an amylase-rich, exudative pleural effusion. Given his history of heavy alcohol use and recurrent epigastric abdominal pain, this presentation suggests chronic pancreatitis resulting in a pancreaticopleural fistula (PPF). Pancreatic fistulas are caused by a disruption of the pancreatic ducts, resulting in leakage of pancreatic digestive enzymes. They are most commonly due to acute or chronic pancreatitis and typically result in the formation of an internal fistula (ie, communication with hollow viscera, pleural/peritoneal cavities). Iatrogenic fistulas can occur after percutaneous drainage of pancreatic cysts or abscesses and typically result in external fistulas (ie, communication with the skin). Fistulas involving the pleural cavity enable pancreatic fluid to enter the pleural space. The resultant pleural effusion is exudative by Light criteria and amylase-rich (ie, pleural fluid amylase exceeding upper limit of normal for serum amylase or a pleural-fluid-to-serum-amylase ratio >1). The pH is typically 7.3-7.5. Manifestations include cough, dyspnea, dysphagia, and chest pain; however, some patients can be asymptomatic. Examination demonstrates decreased breath sounds and dullness to percussion of the affected lung. PPFs tend to recur after thoracentesis. Management includes bowel rest to avoid pancreatic stimulation, enabling the PPF to close. Endoscopic retrograde cholangiopancreatography with sphincterotomy and/or stent placement may be required to promote drainage of pancreatic fluid through the ampulla of Vater instead of the fistula. Refractory cases require percutaneous drainage or surgery. (Choice A) In patients with cirrhosis, a unilateral pleural effusion (eg, hepatic hydrothorax) can develop but is generally right-sided and transudative and would not exhibit high amylase levels. (Choice B) Heavy alcohol use can result in a dilated cardiomyopathy, and volume overload would typically result in bilateral, transudative pleural effusions. (Choices C and F) Empyema and pulmonary tuberculosis are exudative processes; however, both typically result in a low pH (<7.30) and a markedly elevated amylase is unexpected. Tuberculous effusions also typically demonstrate an elevated adenosine deaminase level. (Choice D) An esophageal rupture (Boerhaave syndrome) results in an amylase-rich exudative pleural effusion; however, the pleural fluid pH is typically very low (<6), and undigested food may be present. In addition, Boerhaave syndrome typically occurs in the setting of severe vomiting and chest pain is expected. Educational objective: A pancreaticopleural fistula (between the pancreatic duct and the pleural space) resulting in an amylase-rich exudative pleural effusion occurs most commonly as a result of acute or chronic pancreatitis. Management includes bowel rest to promote fistula closure; endoscopic retrograde cholangiopancreatography may be required. References: Pancreaticopleural fistula: a review. (http://www.ncbi.nlm.nih.gov/pubmed/25640793)

A 54-Year-Old Man Comes to the Emergency Department Due to Shortness