1985 Volume 46 Issue 5 Pages 605-612
Two cases of chronic pancreatitis with mediastinal pancreatic pseudocyst are reported. Pancreatic pleural effusion was also found in one of the cases. In this paper, general concepts of the pathogenesis, diagnosis and treatment of internal pancreatic fistula are also discussed in light of on evaluation of the other 90 cases reported in the Japanese literature.
Case 1: The patient, a 48-year-old man, who complained of dyspnea and back pain, was found to have a large right pancreatic pleural effusion and mediastinal pancreatic pseudocyst. The amylase content of the pleural effusion was 122, 200 S.U./dl, and that of the cystic fluid was 476 S.U./dl. In ERP, the internal fistula was found to be developed from the pancreatic duct to the mediastinum. Cyst-gastrostomy and external drainage of the mediastinal pseudocyst were performed. Case 2: The patient, a 41-year-old man, complained of dysphagia and showed an elevated urine amylase level. An upper gastrointestinal series demonstrated an extra-luminal compression and passage disturbances of the esophagus. In the cystic fluid, both an increased amylase level and an elevated bililubin level were found: 8, 240 S.U./dl and 14.2mg/dl, respectively. Roux-en-Y cyst-jejunostomy was required. The internal pancreatic fistula was considered to be formed secondarily by the pancreatic duct disruption with the leakage of pancreatic secretions directly into the peritoneal or pleural cavity.
The amylase levels in patients are always extremely high in the pleural and ascitic fluid, and diagnosis is confirmed by findings such as internal fistula in ERP. As a rule, patients should be controlled by conservative treatment such as that for acute pancreatitis for several weeks.
If this is not effective, surgical treatment, for example, internal drainage and distal pancreatectomy, is required. Most patients with internal pancreatic fistulae have a successful prognosis, and the course of our cases has been good.
