Study of Pleural effusions of pancreatic aetiology in a tertiary care centre.
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  and most of the effusions are bilateral. The presence of pleural effusion in patients with acute pancreatitis is an indication of more severe pancreatitis.  Pancreatic pseudocyst occurred in nearly a third of the patients with pancreatic pleural effusions. 
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.  Lymphatic communication between pleural and peritoneal lymphatics transfers inflammatory fluid rich in pancreatic enzymes and can cause more exudation into the pleural space.  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.  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.  Most patients with chronic pancreatic pleural effusion are men. In more than 90% of male patients, the pancreatic disease is a result of alcoholism.  Patients with chronic pancreatic pleural effusion have more chest symptoms, because of decompression of pseudocyst. Pleural effusion is predominantly left-sided or bilateral. 
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.
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.
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.
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.  Joseph J et al  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  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  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  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  in their study stressed the importance of studying early serum and pleural fluid amylase and the importance of CT scan and ERCP.
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.
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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.
Dr. Ramakrishna Rachakonda, Sanjeevani Hospital, A1, Ramkuteer Majestic, 3/13, Brodipet, Guntur.
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|
|Date:||Jun 12, 2017|
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