# Hemothorax: When Hemosuccus Pancreaticus Takes an Unexpected Detour to the Chest

## TL;DR

A rare case of bilateral pleural effusion caused by chronic pancreatitis highlights the importance of considering pancreatic origin in such presentations.

## Contribution

This case report emphasizes the atypical bilateral presentation of pleural effusion in chronic pancreatitis and the diagnostic significance of elevated pleural fluid amylase.

## Key findings

- Bilateral pleural effusion can occur in chronic pancreatitis, though typically unilateral and left-sided.
- Elevated amylase in pleural fluid is a key indicator of pancreatic origin.
- Computed tomography angiography is effective in diagnosing hemosuccus pancreaticus.

## Abstract

This case highlights an unusual presentation of bilateral pleural effusion associated with chronic pancreatitis, emphasizing that although pleural effusions are typically unilateral and left-sided, they can occasionally be bilateral. In acute or chronic pancreatitis, pleural effusions are generally transient and resolve once the underlying condition is appropriately managed. While most effusions are left-sided, they may rarely occur on the right side or present bilaterally, as observed in this patient. These effusions are typically exudative, with elevated pleural fluid amylase as a key diagnostic indicator of pancreatic origin.

A 37-year-old male with a history of chronic alcohol consumption initially presented with evidence of a right-sided pleural effusion. Elevated amylase levels in the pleural fluid strongly suggested a pancreatic etiology. After a week of hospitalization, the patient developed a left-sided pleural effusion, further complicating the diagnosis. This is a rare and severe complication of hemosuccus pancreaticus (HP), which can result from hemorrhage through the ampulla of Vater or the pancreatic duct, often due to the rupture of surrounding structures such as the splenic artery. Although HP is a challenging diagnosis, computed tomography angiography (CTA) remains the gold standard for identifying the bleeding source and confirming the diagnosis.

Pancreatitis should be strongly considered when a pleural effusion exhibits elevated amylase levels. Prompt identification and treatment of the underlying pancreatic condition and management of complications such as HP are crucial for resolving the effusion and improving the patient's prognosis. Early diagnosis and intervention generally lead to a favorable outcome, as these effusions are typically transient and resolve with appropriate treatment of the underlying pancreatic disorder.