S3266 Pancreaticopleural Fistula Presenting as Refractory Pleural Effusion: A Rare but Treatable Complication of Alcoholic Pancreatitis

Introduction: Pancreaticopleural fistula (PPF) is an uncommon complication of chronic pancreatitis, characterized by an abnormal ductal communication with the pleural cavity. It typically presents with recurrent pleural effusions and respiratory symptoms, often delaying diagnosis. Timely identification and multidisciplinary intervention are critical to successful outcomes. Case Description/Methods: A 34-year-old man with asthma and significant alcohol use disorder presented with a 3-day history of cough, shortness of breath, nausea, and vomiting. Imaging revealed a large left pleural effusion causing near-complete left lung collapse and a computed tomography abdomen consistent with acute pancreatitis and pancreatic head necrosis. Pleural fluid obtained by thoracentesis was dark brown and exudative, with markedly elevated amylase (6689 U/L), raising concern for a PPF. Despite thoracentesis (2200 mL) and chest tube drainage (1700 mL), effusion persisted. Magnetic resonance cholangiopancreatography (MRCP) demonstrated a dilated pancreatic duct with abrupt tapering at the head and suspected fistulous communication. Endoscopic retrograde cholangiopancreatography (ERCP) confirmed ductal disruption, and a plastic stent was placed after sphincterotomy. Subsequent ERCP involved stone extraction and placement of a fully covered metal stent. The stent was left in place for 6-8 weeks to allow spontaneous closure of the fistula by promoting ductal decompression and epithelial healing. Due to loculated fluid and persistent effusion, video-assisted thoracoscopic surgery (VATS) with decortication and drainage was performed. The patient improved significantly, with normalization of amylase/lipase, resolution of pneumonia, and chest tube removal. He was discharged in stable condition and remained asymptomatic on follow-up. Discussion: This case underscores the importance of considering PPF in young males with recurrent pleural effusions and a history of pancreatitis. The diagnosis hinges on high pleural fluid amylase levels and imaging modalities such as MRCP and ERCP. While medical management with NPO and octreotide may be trialed, endoscopic stenting remains the first-line definitive treatment. VATS is reserved for refractory cases or complicated effusions. Our patient's outcome highlights the benefit of timely ERCP with ductal stenting followed by surgical intervention for definitive fistula resolution.