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Study of Pleural effusions of pancreatic aetiology in a tertiary care centre.

BACKGROUND

Pleural effusions of Pancreatic aetiology are becoming increasingly common in India. A high degree of suspicion is needed, because the treatment is entirely different from the pleural effusions of infectious aetiology. Alcohol is consumed by many even from an young age and patients presenting with pancreatic pleural effusions gave long history of alcohol intake.

Non-malignant pancreatic pleural effusions can occur in acute pancreatitis, chronic pancreatitis, pancreatic pseudocyst and pancreatic ascites [1] and most of the effusions are bilateral. The presence of pleural effusion in patients with acute pancreatitis is an indication of more severe pancreatitis. [2] Pancreatic pseudocyst occurred in nearly a third of the patients with pancreatic pleural effusions. [3]

The exudative pleural effusions in acute pancreatitis result from the transdiaphragmatic transfer of the exudative fluid arising from acute pancreatic inflammation and from diaphragmatic inflammation. [1] Lymphatic communication between pleural and peritoneal lymphatics transfers inflammatory fluid rich in pancreatic enzymes and can cause more exudation into the pleural space. [1] Acute abdominal symptoms dominate in acute pancreatitis and sometimes chest symptoms may mimic pleuritic chest pain and pneumonia. Untreated acute pancreatitis can lead to pseudopancreatic cyst or pancreatic abscess.

Serum amylase and lipase are elevated and pleural fluid levels are often more than serum levels. Levels of serum and pleural fluid amylase are higher in chronic pancreatitis than acute. Pleural fluid in such condition is usual and exudates with high white cell count ranging from 10000 to 50000 with increased neutrophils. [4] In patients of pancreatic pleural effusions, pancreatic pseudocyst or abscesses must be excluded with the help of Ultrasonography or CT scan. These complications have high mortality. [5] Most patients with chronic pancreatic pleural effusion are men. In more than 90% of male patients, the pancreatic disease is a result of alcoholism. [6] Patients with chronic pancreatic pleural effusion have more chest symptoms, because of decompression of pseudocyst. Pleural effusion is predominantly left-sided or bilateral. [6]

MATERIALS AND METHODS

We have investigated patients of pleural effusion having history of alcoholism and abdominal symptom and analysed the pleural fluid. We had a total of 7 patients who fitted into the category of pancreatic pleural effusions. They were all negative for malignancy.

Investigations Done

Complete CBP, ESR, Hb, urine routine, blood sugar, urea, S. creatinine, C-reactive protein, U/S abdomen, Serum LDH, S. lipase, S. amylase, pleural fluid amylase and lipase, serum calcium, and ABG.

RESULTS

We have seven cases of pleural effusion among the patients presenting to Pulmonology Department or referred to us during two years. All the patients are males. Age ranged from 29 to 54 years. Three patients among seven had recurrent pancreatitis. Four patients were diagnosed to have acute pancreatitis for the first time. One patient had pseudopancreatic cyst by ultrasound abdomen and one patient had pancreatic fibrosis. Pleural fluid was exudates in all the patients by Light's criteria. Among our patients of study two patients had right-sided effusions, two patients had left-sided effusions and three patients had bilateral effusions.

All of them gave the history of alcoholism. One patient had high serum triglycerides and had gallstones. One patient was found to be diabetic and he was an occasional alcoholic presenting to Department of Surgery. He had mild azotaemia at the time of presentation with increased triglycerides and multiple gall stones. Serum calcium levels ranged between 7.7 mg% to 9.5 mg%.

Serum amylase and pleural fluid amylase were raised in all the patients. Pleural amylase was more than serum amylase in all but two subjects of our study. Ultrasound abdomen is helpful in the diagnosis. Abdominal symptoms were more common among all the patients. One patient had only abdominal symptoms and no chest symptoms and was diagnosed by chest x-ray.

The first patient in our study was a 29-year-old male with 8 years of history of heavy alcohol intake. The patient presented with shortness of breath, cough and abdominal symptoms. He presented with massive pleural effusion and we put intercostal tube drainage. The fluid was amber coloured like Coca Cola. All the patients were managed symptomatically with antibiotics, Proton pump inhibitors, IV fluids, calcium and supportive drugs. Pleural aspiration was done to relieve the symptoms. They were referred to units of gastroenterology for medical and surgical treatment.

DISCUSSION

Dr. Sumalatha et al presented similar observations in their study of four patients and one of them had pancreatic malignancy. No malignancy was found in our study. [7] Joseph J et al [8] found 25% of cases of amylase rich pleural effusion among 200 patients studied and 16% of them had evidence of pancreatitis. They opined that malignancy is a significant cause of non-pancreatic amylase rich effusions. KB Gupta et al [9] stressed the importance of measurement of isoenzymes of amylase in amylase rich effusions. They found that increased pleural fluid: Serum Amylase ratio of > 1 should indicate the possibility of malignancy. Bedi RS [10] showed in their case report that massive haemorrhagic pleural effusion rich in amylase should warrant the existence of chronic pancreatitis. Mark Z Simmons et al [11] suggested the importance of CT scan of abdomen in identifying minimum pleural effusions in patients with acute pancreatitis and having history of alcohol intake. Anil Sontakke, BO Tayade et al [12] in their study stressed the importance of studying early serum and pleural fluid amylase and the importance of CT scan and ERCP.

CONCLUSION

Pleural effusion of pancreatic aetiology is not uncommon because of increased habit of alcohol intake in our society. Patients presented with long years of heavy alcohol intake. They were all diagnosed by increased pleural fluid and serum amylase levels assisted by clinical and ultrasonography. High degree of suspicion is required in diagnosing these cases, as pancreatic pleural effusions occur in patients with severe pancreatic disease. They may be associated with pseudopancreatic cyst and pancreatic abscess. If not diagnosed and treated, these problems may lead to increased mortality. All the middle-aged males presenting with pleural effusion and abdominal pain must be investigated, particularly those having history of alcohol intake.

REFERENCES

[1] Light RW. Exudative pleural effusions secondary to gastrointestinal diseases. Clin Chest Med. 1985; 6(1):103-11.

[2] Heller SJ, Noordhoek E, Tenner SM, et al. Pleural effusion as a predictor of severity in acute pancreatitis. Pancreas 1997; 15(3):222-5.

[3] Ramesh H, Kuruvilla K. Pleural effusions: a new negative prognostic parameter for acute pancreatitis. Am J Gastroenterol 1995; 90(10):1898-9.

[4] Light RW, Ball WC. Glucose and amylase in pleural effusions. JAMA 1973; 225(3):257-60.

[5] Miller TA, Lindenauer SM, Frey CF, et al. Proceedings: pancreatic abscess. Arch Surg 1974; 108(4):545-51.

[6] Rockey DC, Cello JP. Pancreaticopleural fistula. Report of 7 patients and review of the literature. Medicine 1990; 69(6):332-44.

[7] Sumalatha C. Right sided massive haemorrhagic pancreatic pleural effusions. International Journal of Current Research 2016; 8(7):34198-200.

[8] Joseph J, Viney S, Beck P, et al. A prospective study of amylase-rich pleural effusions with special reference to amylase isoenzyme analysis. Chest 1992; 102(5): 1455-9.

[9] Gupta KB, Ghalaut V, Gupta R, et al. Estimation of serum and pleural fluid amylase and iso-enzyme in cases of malignant pleural effusion. Ind J Tub 2001; 48:87.

[10] Bedi RS. Massive pleural effusion due to asymptomatic pancreatic disease. Lung India 2006; 23(4):163-4.

[11] Simmons MZ, Miller JA, Zurlo JV, et al. Pleural effusions associated with acute pancreatitis: incidence and appearance based on computed tomography. Emergency Radiology 1997; 4(5):287-9.

[12] Sontakke A, Tayade BO. Case series of pancreatic pleural effusion with pancreatico-pleural fistula. JIACM 2014; 15(3-4):245-8.

Ramakrishna Rachakonda (1), Kalyankumar P. V (2), M. Venu (3)

(1) Professor and HOD, Department of Pulmonology, Katuri Medical College, Guntur.

(2) Associate Professor, Department of Pulmonology, Katuri Medical College, Guntur.

(3) Associate Professor, Department of Pulmonology, Katuri Medical College, Guntur.

Financial or Other, Competing Interest: None.

Submission 02-04-2017, Peer Review 31-05-2017, Acceptance 05-06-2017, Published 12-06-2017.

Corresponding Author:

Dr. Ramakrishna Rachakonda, Sanjeevani Hospital, A1, Ramkuteer Majestic, 3/13, Brodipet, Guntur.

E-mail: ramakrishna45@yahoo.co.in

DOI: 10.14260/jemds/2017/789
Table 1. Clinical and Laboratory Evaluation

Sl. No.     Age      Sex         H/O         Pancreatic
of                             Alcohol         State
Patient

s
1.        29 Years   male   Yes, 8 Years     Recurrent
                                            Pancreatitis
2.        46 Years   Male   Yes, 20 Years    Recurrent
                                            Pancreatitis
3.        44 Years   Male   Yes, 21 Years      Acute
                                            Pancreatitis
4.        54 Years   Male   Yes, 30 Years    Recurrent
                                            Pancreatitis
5.        39 Years   Male   Yes, 9 Years       Acute
                                            Pancreatitis
6.        42 Years   Male     16, Years        Acute
                                            Pancreatitis

          50 Years   Male       Only           Acute
7.                           Occasional     Pancreatitis
                               Alcohol

Sl. No.       U/S Abdomen        Serum      Side of    Pleural
of                              Amylase     Pleural     Fluid
Patient                                      Fluid     Amylase

s
1.          Inflammation of     1000IU/L     Right     1600IU/L
               Pancreas
2.         Pseudopancreatic     727IU/L      Left      1727IU/L
                 Cyst
3.        Acute Pancreatitis    964 IU/L   Bilateral   1102IU/L

4.        Pancreatic Fibrosis   624IU/L      Right     450IU/L

5.        Acute Pancreatitis    1100IU/L     Left      1654IU/L

6.        Acute Inflammation    604IU/L    Bilateral   1650IU/L

                 Acute          804 IU/L     Left      670IU/L
7.

Table 2. Serum Triglycerides and
Gallstones by Ultrasonography

Sl. No.       Serum       Gallstones in the U/S
          Triglycerides          Abdomen

1.           225 mg%              None
2.           168 mg%              None
3.           148 mg&              None
4.           156 mg%              None
5.           220 mg%              None
6.           196 mg%              None
7.           296 mg%      Multiple Gall stones

Table 3. Biochemical Profile

Sl. No. of   Fasting Blood   Blood Urea       Serum
Patient        Sugar mg%        mg%       Creatinine mg%

1.                96             34          1.3 mg%
2.                101            44            1.1
3.                77             38            0.9
4.                96             24            0.9
5.                113            33            1.5
6.                107            41            1.4
7.                156            44            1.6

Table 4. Clinical Symptoms and Quantity of Pleural fluid

Sl. No.           Symptoms              Pleural Fluid

1.         Cough, breathlessness,       Massive fluid
              abdominal pain,             occupying
                H/O similar           entire hemithorax
              symptoms before
2.          SOB, abdominal pain         700 cc by U/S
3.            Epigastric pain               450 cc
4.        Epigastric and abdominal          200 cc
              pain, cough SOB
5.          Acute abdominal pain             1 L
6.            Abdominal pain,        600 mL on left side,
               cough and SOB         200 mL on right side
7.          Only abdominal pain,     400 cc on left side
             no chest symptoms

Table 5. Haematological Examination

Sl. No.   Total Count   Polymorphs %     ESR      Hb%

1.           16000          79%        69 mm/hr   64%
2.           14500          80%           74      62%
3.           10900          56%         70 mm     65%
4.           14500          66%           62      53%
5.           11450          70%           59      60%
6.           9700           72%           92      60%
7.           6300           54%           45      70%

Table 6. Pleural Fluid Analysis

l. No.                      Pleural     Glucose   Proteins    Serum
                          Fluid Cells                         Lipase

1. Amber Coloured,        22000/Cumm    84 mg%     3.5 g%    Elevated
2. Resembling Coca Cola                                      464 IU/L
3. Straw Coloured         19000/Cumm    156 mg%    4.2 g%    504IU/L
4. Straw Coloured          1200/Cumm    102 mg%    3.1 g%    432IU/L
5. Straw Coloured         5600/Cu.mm    77 mg%     3.6 g%    532IU/L
6. Straw Coloured          1700/Cumm    122 mg%    2.9 g%    442IU/L
7. Straw Coloured          2700/Cumm    98 mg%     3.6 g%    533IU/L
8. Haemorrhagic           11000/Cumm    224 mg%    3.4 g%    604IU/L

Table 7. Mode of Management

Sl. No.   Procedure     Management         Followup

1.        ICT drain    Conservative   Referred to Higher
                                       Centre for ERCP
2.         Pleural     Conservative      Referred to
          aspiration                  Gastroenterologist
3.         Pleural     Conservative      Referred to
          aspiration                  Gastroenterologist
4.         Pleural     Conservative      Referred to
          aspiration                  Gastroenterologist
5.         Pleural     Conservative      Referred to
          aspiration                  Gastroenterologist
6.         Pleural     Conservative      Referred to
          aspiration                  Gastroenterologist
7.         Pleural     Conservative   Patient was in the
          aspiration                  Surgery Department
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Title Annotation:Case Series
Author:Rachakonda, Ramakrishna; Kalyankumar, P.V.; Venu, M.
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Report
Date:Jun 12, 2017
Words:1900
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