Puncreos
Vol. IS, No. 3, pp. 222-225
0 1997 Lippincott-Raven Publkhers, Philadelphia
Pleural Effusion as a Predictor of Severity in Acute Pancreatitis
Stephen J. Heller, Elizabeth Noordhoek, Scott M. Tenner, Vino Ramagopal,
Matthew Abramowitz, Michael Hughes, and Peter A. Banks
Center for Pancreatic Disease, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A.
Summary: Our objective was to determine whether pleural
effusion is a predictor of severity in acute pancreatitis and, if
so, whether it is an independent predictor. One hundred ninety-
six consecutive cases of acute pancreatitis from October I ,
1994, to September 30, 1995, were reviewed. Medical records
were analyzed for evidence of pleural effusion by chest radio-
graph and severe acute pancreatitis by identification of pancre-
atic necrosis or organ system dysfunction. Data were analyzed
to determine if identification of pleural effusion provided an
early sign of seventy. Among 135 patients who underwent
Pulmonary radiographic abnormalities are common in
acute pancreatitis. Abnormal chest radiographic findings
may be seen in up to 55% of patients (1). Major abnor-
malities include pulmonary infiltrates, pulmonary edema
related to adult respiratory distress syndrome (ARDS),
and pleural effusion. Minor findings include elevation of
the left hemidiaphragm and basilar atelectasis (2,3).
Pleural effusion occurs in 4-17% of patients with
acute pancreatitis (4). The effusions are exudates and
often hemorrhagic. Pleural effusions may or may not be
symptomatic and resolve as the pancreatitis subsides
(2,5). The presence of pleural effusion has been proposed
as a marker for severe pancreatitis. Gumaste et al. noted
an association between pleural effusion on chest radio-
graph obtained within 6 days of admission and severe
disease, as evidenced by Ranson’s criteria and pseudo-
cyst formation (6). Talamini et al. showed a correlation
between pleural effusion on admission chest radiograph
and severe disease, as evidenced by pancreatic necrosis
and death (7). Lankisch et al. described an association
between pleural effusion on computed tomography (CT)
Manuscript received November 6 , 1996; revised manuscript ac-
cepted January 22. 1997.
Address correspondence and reprint requests to Dr. P. A. Banks,
Center for Pancreatic Disease, Brigham and Women’s Hospital, 75
Francis Street, Boston, MA 02115, U.S.A.
222
chest radiography, pleural effusion was seen in 16 of 19
(84.2%) with severe pancreatitis and 10 of 116 (8.6%) of pa-
tients with mild pancreatitis ( p < 0.001). Pleural effusion was
noted in severe pancreatitis prior to clinical or computed to-
mography evidence of severity in only 20% of cases. Pleural
effusion is strongly associated with severity in acute pancreati-
tis but provides independent information on severity in only a
minority of cases. Key Words: Acute pancreatitis-Pleural
effusion.
scan obtained within 72 h of admission and the extent of
pancreatic necrosis, inflammatory changes, and mortality
(8). Maringhini et al. noted a link between pleural effu-
sion on ultrasound and severe disease as defined by the
Atlanta Symposium (organ system dysfunction or local
complications, i.e., necrosis, abscess, or pseudocyst) (9-
11).
In this report, we have evaluated the association be-
tween pleural effusion on chest radiograph and severity
of acute pancreatitis as defined by the Atlanta Sympo-
sium. In addition, we determined whether effusion is
documented early enough to be an independent predictor
of severity.
METHODS
All patients with acute pancreatitis admitted to the
Brigham and Women’s Hospital between October 1,
1994, and September 30, 1995, were included. Two
methods were used to identify cases of acute pancreatitis.
First, all patients given the discharge diagnosis of acute
pancreatitis were reviewed and included in the study if
there was an elevation of serum amylase or lipase to
more than three times the upper limit of normal and if the
clinical presentation was consistent with acute pancreati-
tis. Second, a computer search was performed to identify
 PLEURAL EFFUSION AS A PREDICTOR OF SEVERITY IN PANCREATITIS
all patients with an amylase or lipase elevated to more
than three times the upper limit of normal at least once
during their hospitalization. The medical record of each
patient was reviewed, and the patient was included if the
clinical course was consistent with acute pancreatitis.
Post-endoscopic retrograde cholangiopancreatography
(ERCP) pancreatitis was defined as abdominal pain fol-
lowing ERCP requiring admission to the hospital for
intravenous narcotics, in conjunction with an elevation of
amylase or lipase to more than three times the upper limit
of normal. Cases were excluded from the study if they
met one of the following criteria: pleural effusion on
chest radiograph preceding the development of acute
pancreatitis, a comorbid medical condition that could
lead to effusion (e.g., congestive heart failure), or acute
pancreatitis in a moribund patient as a component of the
terminal illness.
Cases that satisfied inclusion criteria were analyzed
according to demographic data of age, sex, and etiology
of acute pancreatitis. Etiology was identified from the
medical record using the diagnosis of the clinicians car-
ing for the patient. Records were reviewed to determine
whether cases of pancreatitis represented the patient’s
first, second, or more than second episode of acute pan-
creatitis. Cases were classified as mild or severe pancre-
atitis. Pancreatitis was considered severe in the presence
of one of the following: necrosis as demonstrated by
dynamic contrast-enhanced CT scan, surgical pathology,
or autopsy or organ system dysfunction as reflected by
hypotension (systolic blood pressure <90 mm Hg or de-
pendence on intravenous pressors), hypoxemia (Pao,
<60 mm Hg breathing room air), renal insufficiency (el-
evation of serum creatinine above 2 mg/dl in the absence
of preexisting renal insufficiency), or significant gastro-
intestinal bleeding (9,lO).
Reports of chest radiographs performed at any time
during the hospitalization were reviewed for the presence
of pleural effusions. In cases of acute pancreatitis trans-
ferred to our hospital, reports of chest radiographs per-
formed at the referring hospital were reviewed for the
presence of pleural effusion. Statistical analysis was per-
formed using Fisher’s exact test.
RESULTS
A total of 196 cases of acute pancreatitis in 162 pa-
tients was included in the study. The mean age was 45. l
years (range, 19-89). Males were 40.7% of the study
population; females, 59.3%. Chest radiographs were per-
formed in 135 of 196 cases: 116 of 176 cases (65.9%) of
mild acute pancreatitis and 19 of 20 cases (95.0%) of
severe disease.
223
Table 1 classifies acute pancreatitis by severity and
etiology. Alcohol was the most common etiology
(28.6%), followed by idiopathic (20.4%), ERCP
(20.4%), and gallstones (18.4%). Severe acute pancreati-
tis comprised 10.2% of all cases, and mild pancreatitis
comprised 89.8%, Three patients died from severe acute
pancreatitis: two of three had pleural effusion on chest
radiograph; the other patient underwent no radiography
after admission.
Table 2 shows the relationship of pleural effusion to
etiology and severity in acute pancreatitis. Of 116 pa-
tients with mild pancreatitis who underwent chest radi-
ography, 10 had pleural effusion (8.6%). Of 19 patients
with severe pancreatitis who underwent chest radiogra-
phy, 16 had pleural effusion (84.2%). This difference is
statistically highly significant 0, < 0.001). As a test for
the presence of severe disease, pleural effusion had a
sensitivity of 84.2% and a specificity of 91.4% (positive
predictive value, 61.5%; negative predictive value,
97.2%). However, there was no significant correlation
between the etiology of pancreatitis and the incidence of
pleural effusion.
We wanted to establish that the difference in rates of
pleural effusion between mild and severe pancreatitis
was not related to a difference in the number of previous
episodes of acute pancreatitis. To evaluate the number of
previous episodes of acute pancreatitis as a possible con-
founder, we compared the rate of pleural effusion in mild
and severe pancreatitis in the subset of patients suffering
from their first or second bout of pancreatitis. Of the 62
patients with mild pancreatitis and fewer than two prior
episodes, 5 (8.1%) had pleural effusion. Of the 16 pa-
tients with severe pancreatitis and fewer than two prior
episodes, 14 (87.5%) had pleural effusion. As these re-
sults are very similar to those obtained for all patients
disregarding the number of prior episodes of pancreatitis,
we conclude that pleural effusion is linked with severity
of disease rather than number of prior episodes.
Results of pleural effusion by anatomic location are
reported in Table 3. Effusions were bilateral in 18 of 26
(69.2%), left-sided in 7 of 26 (26.9%), and right-sided in
I of 26 (3.9%). The distribution of effusions was similar
in mild and severe pancreatitis: bilateral effusions com-
TABLE 1. Acute pancreatitis (AP): etiology and severity
Etiology n (%I Mild AP Severe AP
Alcohol 56 (28.6) 51 5
Idiopathic 40 (20.4) 37 3
ERCP 40 (20.4) 38 2
Gallstones 36 (18.4) 29 7
Miscellaneous 24 (1 2.2) 21 3
Total 196 176 (89.8) 20 (10.2)
Puncreas. Vul. 15, No. 3, 1997
224 S. J. HELLER ET AL.

TABLE 2. Pleural effusion (PE): relationship to etiology gan failure or pancreatic necrosis. Of the seven patients
and severity of acute pancreatitis (AP) in whom pIeural effusion preceded severity, in six we
PWtotal were able to calculate Apache I1 scores during the first 48
h of hospitalization to determine whether the presence of
Etiology Mild AP (%) Severe AP (%) Total (%)
effusion provided evidence of severity not already re-
Gallstone\ 2/20 (10) 5/7 (71) 7/27 (26) flected by an accepted standard. Only three of six had
Alcohol 2/37 ( 5 ) 41.5 (80) 6/42 (14)
ERCP 2/17 (12) 1/1 (100) 3/18 (17) scores <8 during the first 48 h of hospitalization. There-
Idiopathic 412 (14) 313 (100) 7/32 (22) fore, of the 14 patients with complete data including
Other 0/13 (0) 313 (100) 3/16 (19) Apache I1 scores, in only three (21.4%) did effusion
Total 10/1 16 (8.6) 16/19 (84.2) 261135 (19.3)
predict severity in the absence of other readily identifi-
able predictors of severity, namely, necrosis, organ dys-
prised 75% of all effusions in severe disease and 60% of function, or an elevated Apache 11 score. Since the pa-
all effusions in mild disease. tient with pleural effusion on admission also had el-
To determine whether the presence of pleural effusion evated Apache I1 scores in the initial 24 h, in only three
provided an early, independent predictor of severity in of 15 (20%) was pleural effusion an independent predic-
acute pancreatitis, we determined whether the pleural tor of severity.
effusion was present at admission. Eighteen patients with
severe pancreatitis underwent chest radiography on ad- DISCUSSION
mission; only one had a pleural effusion. To ensure that
the effusions detected after admission were detected in a Previous reports have noted a correlation between
timely fashion, we determined the time interval between pleural effusion and severity in acute pancreatitis, as evi-
the previous chest radiograph showing no effusion and denced by pseudocysts (6,8), necrosis (7,8), and mortal-
the chest radiograph that identified the effusion. Of the ity (7,8). A recent study linked pleural effusion detected
15 patients who were noted to have pleural effusion after by ultrasonography with severe pancreatitis in accor-
admission, 9 (60.0%) had a negative chest radiograph 1 dance with criteria outlined by the Atlanta Symposium
day before the effusion was documented, and 13 (86.7%) (9). However, none of these studies evaluated pleural
had a negative chest radiograph 2 days prior to docu- effusion detected by chest radiography as a predictor of
mentation of the effusion. We therefore conclude that severity using the Atlanta criteria.
pleural effusion is rarely present at admission; the later The data from this report are the first to demonstrate a
detection of pleural effusions was due to a delay in onset correlation between pleural effusion on chest radiograph
rather than a delay in detection. and severity in accordance with the Atlanta criteria. The
We then evaluated whether pleural effusion was iden- findings of this study confirm the link between pleural
tified before or after recognition of severe disease by effusion and severity of acute pancreatitis. Pleural effu-
standard criteria: necrosis, organ failure, or Apache I1 sion on chest radiograph had a sensitivity of 84.2% and
score >8. In the 15 cases of severe pancreatitis and pleu- a specificity of 91.4% for severe disease, as manifested
ral effusion documented after admission, the median day by pancreatic necrosis or organ failure.
of documentation of effusion was hospital day 3.5 However, this report also shows that pleural effusion
(range, 2-9). We compared the day of documentation of is rarely an early, independent predictor of severity. Only
pleural effusion with the day of documentation of sever- 1 of 18 patients with severe pancreatitis who underwent
ity by the Atlanta criteria (organ failure or CT scan dem- admission chest radiography had a pleural effusion on
onstrating necrosis). Of the 15 patients, in 7 (46.7%) admission. Of the 15 patients with severe pancreatitis
documentation of effusion preceded identification of or- who developed pleural effusion after admission, 13 had a
negative chest radiograph within 2 days of the documen-
TABLE 3. Pleural effusions: relationship of severity to tation of effusion. This finding demonstrates that the
anatomic location identification of pleural effusion after admission reflects
Mild AP Severe AP the actual clinical course rather than delayed detection of
(n = 116) (n = 19) Total (%) an existing effusion. Pleural effusion demonstrated se-
Left-sided 3 4 7 (26.9) verity earlier than standard criteria in only 20% of cases.
Right-sided I 0 1 (3.8) Because the most severe bouts of acute pancreatitis
Bilateral 6 12 18 (69.2) generally occur during the patient’s first or second epi-
Totdl 10 16 26
sode (12), we wanted to establish that the difference in
AP, acute pancreatitis. rates of pleural effusion between mild and severe pan-

Puncreus. Vol. 15, No. 3. 1997

 PLEURAL EFFUSION AS A PREDICTOR OF SEVERITY IN PANCREATITIS
creatitis was not due solely to a difference in the number
of prior episodes. To clarify this issue, we evaluated the
subset of patients with fewer than two prior episodes of
acute pancreatitis. We found that within this subset, 8. I %
of patients with mild pancreatitis and 87.5% of patients
with severe pancreatitis had pleural effusion. The differ-
ence in rates of pleural effusion persisted after control-
ling for number of prior episodes. From these data, we
conclude that the incidence of pleural effusion correlates
with the severity of pancreatitis, not the number of prior
episodes.
We wanted to determine whether pleural effusion was
associated with the etiology of acute pancreatitis. Our
study found no relationship between the etiology of acute
pancreatitis and the development of pleural effusion.
This finding corroborates those of Lankisch et al. (8) and
Maringhini et al. (9) but contradicts the findings of Gu-
maste et al. (6), who found a higher incidence of pleural
effusions in alcoholic than gallstone pancreatitis. From
our findings we conclude that effusion is related to se-
verity but not etiology.
We investigated whether there was a link between the
severity of pancreatitis and the anatomic location of
pleural effusions. This report found no relationship be-
tween severity of acute pancreatitis and anatomic distri-
bution of pleural effusions. In both mild and severe dis-
ease, the majority of effusions was bilateral. Thus it ap-
pears that the site of pleural effusion offers no additional
prognostic information. Our results corroborate those of
Lankisch et al. ( 8 ) , who reported that 7 7 % of pleural
effusions were bilateral. In contrast, in the series by Gu-
maste et al. (6) and Maringhini et al. (9), left-sided ef-
fusions were most frequent (55 and 60%, respectively).
The significance of this discrepancy is unclear.
225
To summarize, pleural effusion is associated with se-
verity in acute pancreatitis but predicts severity indepen-
dently in only 20% of cases. Admission chest radio-
graphs are rarely helpful. However, if a patient is noted
to have pleural effusion without other manifestations of
severity, the clinician should remain vigilant for the de-
velopment of severe disease.
REFERENCES
1. Kaye MD. Pleuropulmonary complications of pancreatitis. Thorux
1968;23:297-306.
2. Shapiro MS, Dobbins JW, Matthay RA. Pulmonary manifestations
of gastrointestinal disease. Clin Chest Med 1989;10:61743.
3. Lankisch PG, Droge M, Becher R. Pulmonary infiltrations: sign of
severe acute pancreatitis. Znt J Puncreatol 1996;19:113-5.
4. McKenna JM, Chandrasekhar AJ, Skorton D, Craig RM, Cugell
DW. The pleuropulmonary complications of pancreatitis. Chest
1977;71:197-204.
5. Basran GS, Ramasubramanian R, Verma R. lntrathoracic compli-
cations of acute pancreatitis. Br J Dis Chest 1987;81:326-31.
6. Gumaste V, Singh V, Dave P. Significance of pleural effusion in
patients with acute pancreatitis. Am J Gastroenterol 1992;87:
871-4.
7. Talamini G, Bassi C, Falconi M, et al. Risk of death from acute
pancreatitis: role of early, simple “routine” data. Int J Pancreatol
1996;19:15-24.
8 . Lankisch PG, Droge M, Becher R. Pleural effusions: a new nega-
tive prognostic parameter for acute pancreatitis. Am J Gastroen-
terol 1994;89:1849-51.
9. Maringhini A, Ciambra M, Patti R, et al. Ascites, pleural, and
pericardial effusions in acute pancreatitis. Dig Dis Sci 1996;41:
848-52.
10. Bradley EL. A clinically based classification system for acute pan-
creatitis. Arch Surg 1993;128:586-90.
I 1 , Banks PA. A new classification system for acute pancreatitis. Am
J Gustroenterol 1994;89:151-2.
12. Ranson JHC. Etiological and prognostic factors in human acute
pancreatitis: a review. Am J Casrruenterol 1982;77:633-8.
Pancreas, Vol. IS, N o . 3, 1997