ABSTRACT:
We report a relatively uncommon association of massive pleural effusion (left) with pancreatic pseudocyst in an adult male patient. The pathophysiology, clinical features diagnosis and management of this conditions are reviewed. (The Ind. Pract 2004; 57(8): 553-554).

Key Words: Pancreatic Pseudocyst, Pleural Effusion

INTRODUCTION
Pseudocysta are localized collections of panecreatic secretions that lack and epithelial lining and persist for more than 4 weeks. In the past pseudocysts were detected. indirectly by clinical suspicion, appearance of a palpable abdominal mass and from barium contrast studies that demonstrated a mass. The advent of pancreatic imaging by ultrasonography and CT Scan has lead to the realization that pseudocysts appear in 10% patients with acute pancreatitis.

A variety of clinical and radiographic finding have been associated wit pancreatitis and pleural effusion is one of them. pleural effusion may be bilateral, confined to left side or rarely right sided and may be massive.

CASE REPORT
A 50 year old male patient admitted with history of chest pain for 1 month, swelling of abdmen with upper abdominal pain for 1 month, loss of appetite with nausea for 15 days and dyspnoea for last 3 days. Six months prior to admission he was provisionally diagnosed to be a case of pulomonary tuberculosis with left sided pleural effusion and was on treatment with ATT (4 drugs) for 6 months without any clinical improvement. He is not a known case of DM, HTN, SCD. No history of intake of other drugs. He is a chronic alcoholic for last 20 years.

On examination the patients was of average built with mild pallor, no icterus, no lymphadenopathy, with a pulse rate of 76 per minute, regular BP=118/80 mmHg. Cardiavascular system examination revealed apex beat Rt. 5th ICS. Chest examination revealed trachea shifted to right side. on left side reduced movement , stony dull percussion note, vocal response absent, breath sound diminished. Per abdomen examination revealed mild hepatomegaly with a firm intra abdominal swelling palpable in the middle left upper abdominal region, non tender with irregular margin.

INVESTIGATIONS
Hb = 8.6gm%
TLC = 8000/mm3
DC =N-60% , E-4%, L-36%
ESR =25mm 1st hr
FBS = 92mg%
Urine =NAD
S. urea = 38mg%
S. Creatinine = 1.1 mg%
Na+ = 135m.mol/L
K+ = 3.4 m.mol/L

Pleural fluid analysis revealed , coffee coloured, haemorrhage fluid with TLC could 700 mm3 mostly mestothelial cells mixed with cellular elements of blood. No malignant cells seen. Biochemical study revealed glucose- 60mg% protein – 1.6mg%. LDH- 2280IU/L Amylase- 30 IU/L.

Chest X- ray (PA view0 reveals massive pleural effusion (lt) with trachea shifted to rt.side. USG abdomen and pelvis reveals head of pancreas normally seen but the body and tail could not be visualized. A large cystic lesion of 15cm x 12cm with echogenicity seen with left sided pleural effusion.

The patient was diagnosed as a case of pancreatic pseudocyst with left sided pleural effusion due to acute pancreatitis probably alcohol induced. Pleural tapping was done and about 3000ml of haemorrhagic fluid was drawn out. He was put on of loxacin. valdecoxib, haematinics and other supportive treatment. The patient showed marked improvement during hospital stay and planned for surgical management for the existing pseudocyst.


DISCUSSION

Pancreatic pseudysts are collections of tissues, fluid debris enzymes and blood which develop over a period of 4 weeks after the onset of acute pancreatitis and constitute about 10% of patients of acute pancreatitis. It is encountered most frequently with alcoholic panaceatitis. Pseudocysts associated with pleural effusion are most common on the left but may be bilateral and rarely limited to right pleural space (Gumaste Singh, Dave et a, 1992) it is assumed to be a new prognotic parameters for acute pancreatitis (Lankisch Droge, Becher et al1994).

Psyeuodycysts lack epithelial lining and disruption of the pancreatic ductal system is common. Approximatelty 85% are located in the body or tail of pancreas and 15% in the head. If the pancreatic duct disruption is posterior, an internal fistula may be develop between the pancreatic duct and the pleural space producing a pleural effusion which is usually left sided and often massive. Conservative therapy is indicated if the pseudocyst is shrinking evidenced by serial ultrasound and minimal symptoms pseudocysts (every 3 to 6 months) Long acting somatostatin anagogic octreotide which inhibits pancreatic secretion is useful in cases of pancreatic ascetics with pleural effusion.

Pseudocyst with communicating duct if strictured require internal surgical or endoscopic drainage. Transgastric percutaneous approach is favoured. Associated massive left sided pleural effusion often required thoracentesis or chest tube drainage. A disrupted pancreatic duct can be treated by stenting.

CONCLUSION

Association of the left sided massive pleural effusion with pancreatic pseudocyst is relatively uncommon. However, additional studies are needed to substantiate these results.

REFERENCES
1. Gumaste V., Singh, V., Dave P. Significance of pleural effusion in patients with acute pancreatitis. Am J. Gastroenterilogy 1992; 87: 871.
2. Lankisch P.,G. Droge M and Becher R. Pleural effusion : A new negative prognostic parameter for acute pancreatitis. Am J Gateroesterol 1994; 89: 1849.
3. Slesinger and Fordtran’s Gastrointestinal and liver disease (6th edn) vol1 Sleisenger Feldman Scharshmidt Klein (W.B Saunders Co) 815:826:836.
4. TB of Gastroenterology (Vol-II) 2nd Edn Year 1995 (T. Yamada. J.B. Lippincott Co. Philadelphia ) page 2078-84.
5. Harrisons principles of Int. Medicine 15th Edn Vol 2 year 2001: Page-1798.