胰腺胸膜瘘致反复大量血性胸腔积液一例

Recurrent massive bloody pleural effusion caused by pancreatic pleural fistula in a case

目的介绍胰腺胸膜瘘引起大量血性胸腔积液患儿的早期临床特点及诊治要点。方法报道1例胰腺胸膜瘘患儿临床症状、体征、辅助检查及诊治方法。结果4岁男孩，间断发热、咳嗽、胸闷和胸痛1个月，胸腔闭式引流3次均为血性胸液，腹部无阳性体征，腹部B超提示胰腺回声粗糙，血和胸腔积液胰淀粉酶分别为495 U／L和35938 U／L，开胸探查发现有一瘘管从胸腔通向胰腺，经全胃肠外营养、静脉滴注生长抑素以及内镜逆行胰胆管造影在胰管内放置支架治愈。结论胰腺胸膜瘘患儿早期以呼吸症状为主，缺乏腹部症状，易造成诊治延迟。胸腔积液中胰淀粉酶显著增高是诊断本病的重要线索和依据，本病如保守治疗失败需行内镜逆行胰胆管造影检查和治疗。

Objective To introduce the early clinical features and the main points of diagnosis and treatment of children with pancreatic pleural fistula presenting massive bloody pleural effusion. Method The clinical data of symptoms, signs, laboratory examination, diagnosis and treatment methods of pancreatic pleural fistula in a child are presented. Result A 4-year-old boy presented with one month history of intermittent fever, cough, chest tightness and chest pain. His pleural effusion collected from three thoracic closed drainage was hemorrhagic. He had no positive abdominal signs. His abdominal B-mode uhrasonography showed rough pancreatic echo. The levels of amylase in blood and pleural fluid were 495 U/L and 35 938 U/L, respectively. There was a fistulous tract from the thoracic cavity leading to the pancreas at thoracic surgical exploration. The child was cured by total parenteral nutrition, intravenous infusion of somatostatin and a stent placed in the pancreatic duct by endoscopic retrograde cholangiopancreatography （ERCP）. Conclusion The child with pancreatic pleural fistula in early stage mainly present respiratory symptoms and lack abdominal symptoms, so the diagnosis and treatment is often delayed. Significant increase of pancreatic amylase level in pleural effusion can be an important clue and basis for the diagnosis. If conservative therapy fails, the examination and treatment with ERCP should be considered.