Answer for BIR CoW 19 Feb 2023
Pancreatico-pleuro fistula and left inferior phrenic artery pseudoaneurysm
Findings
A Frontal Plain Chest Radiograph showed homogenous radio-opacity in the entire right hemithorax (White-out right hemithorax), with no evidence of calcification or air bronchogram within the opacity. There is shift of the mediastinum to left. (Gross right pleural effusion) [1]. Contrast Enhanced Computed Tomography (CT) showed pancreatic parenchymal atrophy with an irregular contour. The main pancreatic duct appears dilated, and measures 10 mm with few ductal calculi/calcifications and sludge seen within the ductal system. (Chronic Calculous Pancreatitis) [2,3]. There is a well-defined thin-walled collection in the splenic hilum measuring about 3.5 x 2.4 cm (Pseudocyst) [4]. There is disruption of the duct at the body region which is seen communicating with this pseudocyst. (Duct Disruption). The pseudocyst is seen tracking into the posterior mediastinum through the oesophageal hiatus and extending into the right pleural cavity. (Pancreatico-pleural fistula) [5,6]. Moderate free fluid and pneumothorax were noted in the right pleural cavity with an ICD tube in situ and, minimal free fluid was noted in the abdomen and left pleural cavity. The pleural fluid analysis showed elevated amylase levels. She developed acute bleed [300 ml of frank blood] in the drain tube for which CT angiography was performed which showed a small focal outpouching measuring about 3x2 mm in the proximal left inferior phrenic artery with minimal bleed in the left subdiaphragmatic region extending into the right pleural cavity. (Pseudoaneurysm with bleed) [7,8]
Discussion
This was a young female child with chronic pancreatitis with duct disruption, pseudocyst and pancreatico-pleural fistula with right haemothorax and a left inferior phrenic artery pseudoaneurysm as the source of the bleed. There was no active leak in the CT angiogram, hence was conservatively managed and had no further acute bleeding episodes. Surgical excision of the pseudocyst with distal pancreatectomy, excision of the fistulous tract and splenectomy was performed due to dense adhesions of pseudocyst; and is now on outpatient follow-up.
Supplementary reference articles for further reading:
1. Ortiz Morales CM, Girela Baena EL, Olalla Munoz JR, Parlorio de Andrés E, López Corbalán JA. Radiology of acute pancreatitis today: The Atlanta classification and the current role of imaging in its diagnosis and treatment. Radiología. 2019; 61:453-466. 2. Foster B.R., Jensen K.K., Bakis G., Shaaban A.M., Coakley F.V. Revised Atlanta classification for acute pancreatitis: a pictorial essay. Radiographics. 2016; 36: 675-687 3. Owen J. O'Connor, Juliette M. Buckley, Michael M. Maher. Imaging of the Complications of Acute Pancreatitis. AJR 2011; 197: W375–W381
Findings
A Frontal Plain Chest Radiograph showed homogenous radio-opacity in the entire right hemithorax (White-out right hemithorax), with no evidence of calcification or air bronchogram within the opacity. There is shift of the mediastinum to left. (Gross right pleural effusion) [1]. Contrast Enhanced Computed Tomography (CT) showed pancreatic parenchymal atrophy with an irregular contour. The main pancreatic duct appears dilated, and measures 10 mm with few ductal calculi/calcifications and sludge seen within the ductal system. (Chronic Calculous Pancreatitis) [2,3]. There is a well-defined thin-walled collection in the splenic hilum measuring about 3.5 x 2.4 cm (Pseudocyst) [4]. There is disruption of the duct at the body region which is seen communicating with this pseudocyst. (Duct Disruption). The pseudocyst is seen tracking into the posterior mediastinum through the oesophageal hiatus and extending into the right pleural cavity. (Pancreatico-pleural fistula) [5,6]. Moderate free fluid and pneumothorax were noted in the right pleural cavity with an ICD tube in situ and, minimal free fluid was noted in the abdomen and left pleural cavity. The pleural fluid analysis showed elevated amylase levels. She developed acute bleed [300 ml of frank blood] in the drain tube for which CT angiography was performed which showed a small focal outpouching measuring about 3x2 mm in the proximal left inferior phrenic artery with minimal bleed in the left subdiaphragmatic region extending into the right pleural cavity. (Pseudoaneurysm with bleed) [7,8]
Discussion
This was a young female child with chronic pancreatitis with duct disruption, pseudocyst and pancreatico-pleural fistula with right haemothorax and a left inferior phrenic artery pseudoaneurysm as the source of the bleed. There was no active leak in the CT angiogram, hence was conservatively managed and had no further acute bleeding episodes. Surgical excision of the pseudocyst with distal pancreatectomy, excision of the fistulous tract and splenectomy was performed due to dense adhesions of pseudocyst; and is now on outpatient follow-up.
Supplementary reference articles for further reading:
1. Ortiz Morales CM, Girela Baena EL, Olalla Munoz JR, Parlorio de Andrés E, López Corbalán JA. Radiology of acute pancreatitis today: The Atlanta classification and the current role of imaging in its diagnosis and treatment. Radiología. 2019; 61:453-466. 2. Foster B.R., Jensen K.K., Bakis G., Shaaban A.M., Coakley F.V. Revised Atlanta classification for acute pancreatitis: a pictorial essay. Radiographics. 2016; 36: 675-687 3. Owen J. O'Connor, Juliette M. Buckley, Michael M. Maher. Imaging of the Complications of Acute Pancreatitis. AJR 2011; 197: W375–W381
Note:
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!