|Year : 2006 | Volume
| Issue : 4 | Page : 163-164
Massive pleural effusion due to asymptomatic pancreatic disease
Bedi Nursing Home, 21, Fateh Colony, Near Phuwara Chowk, Patiala-147001(Punjab)., India
R S Bedi
Bedi Nursing Home, 21, Fateh Colony, Near Phuwara Chowk, Patiala-147001(Punjab).
Source of Support: None, Conflict of Interest: None
Clinical trial registration None
| Abstract|| |
A Case of massive haemorrhagic pleural effusion with high amylase levels secondary to asymptomatic pancreatic disease is reported. It is suggested that pleural fluid amylase content should be measured in any case of exudative pleural effusion of unknown aetiology.
Keywords: pancreatitis, amylase, pleural effusion.
|How to cite this article:|
Bedi R S. Massive pleural effusion due to asymptomatic pancreatic disease. Lung India 2006;23:163-4
| Introduction|| |
Small and transient pleural effusion is a feature of acute pancreatitis, while massive effusion, though uncommon, is the feature of chronic pancreatitis. The underlying pancreatic disease is often asymptomatic, and therefore the diagnosis can be missed. We report a patient who developed massive haemorrhagic pleural effusion with high amylase concentrations.
| Case Report|| |
A 45 Year old male chronic smoker, chronic alcoholic farmer presented with left sided chest pain, dry cough and progressively increasing breathlessness of two weeks duration. He gave history of mild episodes of pain abdomen off and on in the past, but denied any such pain or other abdominal complaint during the last one year.
Except for increased respiratory rate, all other vital parameters were normal. Chest examination revealed increased volume of left hemithorax with markedly reduced breath sounds. Cardiovascular, abdominal and neurological examination was unremarkable.
Chest radiograph revealed a massive left sided pleural effusion with mediastinal shift to the right [Figure 1]. His haemoglobin was 11 gm%, ESR 98mm 1st Hr. westergen; total leucocyte count 11,000 per cumm with 82% neutrophils, 14% lymphocytes, 2% eosinophils and 2% monocytes. Fasting blood sugar, liver and renal biochemical parameters were within normal range. Serum amylase was 159 U per liter (Normal up to 140 U per liter).
A total of 6 liter of pleural fluid was aspirated in four sittings spread over 3 days. Pleural fluid was haemorrhagic exudate (proteins 3.6 gm%), had red cell counts of 22,500 per cumm, white cell counts of 3880 per cumm with 95% neutrophils and 5% lymphocytes [Figure 2]. Pleural fluid was negative for malignant cells and acid fast bacilli and no organisms were cultured. In view of elevated serum amylase levels, pleural fluid amylase was tested and found to be 1800 U per liter.
The ultrasonography of abdomen and UGI endoscopy were normal. The computed tomography (CT) of thorax using contrast showed left sided pleural effusion. Fiberoptic bronchoscopy was normal.
In view of markedly elevated pleural fluid amylase levels and exclusion of other causes, a diagnosis of pleural effusion due to asymptomatic pancreatic disease was made. Patient was advised CT abdomen, endoscopic retrograde cholangiopancreatography (ERCP) and surgical management, but he refused due to financial constrains and fear of surgery and was lost during follow up.
| Discussion|| |
The incidence of pleural effusion with acute pancreatitis in older reports was about 3-7%  , but it is nearing 50% in recent reports based on pleural fluid detection by CT  . The pleural effusion in chronic pancreatitis though uncommon, does occur, but is often missed because of lack of abdominal symptoms.
That the massive effusion was secondary to pancreatitis was confirmed by estimation of pleural fluid amylase levels (which were markedly elevated) and serum amylase levels (which were only mildly raised). The only other two conditions which can lead to raised pleural fluid amylase levels like malignant tumor and oesophageal rupture  were excluded by carrying out detailed investigations like UGI endoscopy, abdominal ultrasonography, CT of thorax and by pleural fluid cytology. Investigations like ERCP and abdominal CT could not be carried out as patient refused due to financial constrains. Most patients of chronic pancreatic pleural effusion are men and fluid is usually left-sided. The pleural effusion is usually large, some times occupying the entire hemithorax. In 20% cases the fluid can be right sided and in 15% bilateral  .
The accumulation of amylase rich pleural fluid may be due to transfer of pancreatic secretions through transdiaphragmatic lymphatics  , or the direct contact of pancreatic enzyme with the diaphragm may lead to rupture or perforation. In most cases, a pancreatico-pleural fistula can be demonstrated either by ERCP or by CT.
Because chest symptoms dominate the clinical picture and often patients have no history of prior pancreatic disease, the diagnosis is easily missed. The best screening test for chronic pancreatic pleural effusion is the measurement of pleural fluid amylase (which is markedly elevated, usually over 1000 U per Liter), where as the serum amylase may be normal or mildly elevated  . CT chest as well as abdomen and ERCP are required for confirmation of diagnosis and for planning surgery.
Pancreatic disease is not readily recognized as a cause of massive pleural effusion. Since the underlying pancreatic disease is commonly asymptomatic, it is suggested that the pleural fluid amylase content should be measured in any case of recurrent exudative pleural effusion of unknown aetiology.
| References|| |
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[Figure 1], [Figure 2]