Over the past decade ascites and pleural effusions have become recognized as complications of chronic inflammatory disease of the pancreas. In the setting of heavy alcoholic intake, but usually without symptoms, a disruption of the main pancreatic duct can occur, resulting in an internal fistula between the duct and peritoneal cavity, producing massive ascites. If the duct disruption is posterior, pancreatic secretions can track up into the mediastinum and then escape into one or both pleural spaces, resulting in an internal fistula between the pancreatic duct and pleural space, producing a massive effusion. Diagnosis of the internal pancreatic fistula can be made by finding high amylase and albumin levels in the ascitic or pleural fluid. Serum amylase is usually, but not always elevated. Treatment initially should be nonoperative, and should include intravenous hyperalimentation, nasogastric suction, Diamox and atropine administration, and either multiple paracenteses, or multiple thoracenteses, or a chest tube insertion. If medical management is unsuccessful after a 2- or 3-week trial, surgical intervention is indicated. Pancreatography is essential to define the pathological pancreatic duct anatomy. When the duct pathology is determined, and the internal fistula identified, an appropriate drainage or resectional procedure can be chosen. With this regimen, most patients with an internal pancreatic fistula should be managed successfully.
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