Spontaneous gastropleural fistula - a cause of high amylase effusion

R. Dua*^a (Dr), N. Baishya^a (Dr), A. Kp^a (Dr), R. Singh^b (Dr), I. Patnaik^b (Dr)

^a AIIMS , Rishikesh, INDIA ; ^b aiims, Rishikesh, INDIA

* ruchi.pulm@aiimsrishikesh.edu.in

Background

Spontaneous Gastro pleural fistula as a cause of high amylase effusion secondary to perforated gastric ulcer is a rare entity.

Case Report

A 35-year chronic alcoholic male, presented with intermittent and radiating epigastric pain for 2 years. Over last 15 days he complained of sudden onset left-sided chest pain and progressive breathlessness.A chest X-ray showed left-sided hydropneumothorax following which intercostal drainage was inserted .Pleural fluid analysis revealed exudative, neutrophilic effusion with high amylase levels(749 IU/ml) while serum amylase and lipase were within normal range. CECT abdomen and thorax followed by MRCP was performed for pancreatitis which was normal.

Oral contrast study was then performed to look for esophageal perforation which revealed no abnormality. In view of persistently elevated pleural fluid amylase levels and high volume drain(>1 litre daily with debris), an upper gastrointestinal endoscopy was then performed which showed a large clean base ulcer ( 8cmx6cm) with a fistulous opening. A 1cm guide wire could be negotiated across ulcer base to the thoracic cavity.

A NJ tube was inserted , fistulous communication was clipped via upper Gastrointestinal endoscopy . Patient has been planned for surgical repair once the general condition improves.

Discussion

GPF have been uncommonly encountered usually post surgeries(gastric bypass , pulmonary resection,splenectomy )^1-3,post trauma, malignancies( gastric lymphoma, Ewing’s sarcoma ) ,as complication of concomitant chemo-radiotherapy⁴ and rarely following bevacizumab chemotherapy⁵. Perforated gastric ulcer is a rare cause of GPF .In this case neither CT evaluation nor oral contrast oesophagogram could demonstrate the cause of high volume ICD drain .Direct visualisation by endoscopy proved to be clinching.

Conclusion

Recognising GPF as a rare complication of perforated gastric ulcer is necessary to avoid both delayed diagnosis and unwarranted morbidity / mortality. Direct visualisation by endoscopy should be done in setting of unexplained high amylase ,high output intercostal drains.

Disclosure of funding source(s): none