Moderately Severe Acute Pancreatitis Complicated by Right-Sided Pancreaticopleural Fistula: A Rare Presentation of Massive Recurrent Hemorrhagic Effusion.

Pancreaticopleural fistula (PPF) is a rare complication of pancreatitis, occurring in <1% of cases, typically presenting with left-sided pleural effusions. Right-sided PPFs are even more uncommon, with an estimated incidence of 0.076%, which can delay recognition. We report a 50-year-old man with alcohol-related pancreatitis who developed a massive, recurrent right-sided pleural effusion. Initial thoracentesis drained 1.5 L of dark, amylase-rich fluid, followed by a subsequent single-tap drainage of 5.2 L, with a cumulative drainage volume of 13.9 L during the admission. Endoscopic retrograde cholangiopancreatography demonstrated a mid-pancreatic duct leak, and a 7 Fr × 5 cm transpapillary stent was placed. Computed tomography imaging confirmed a fistulous tract communicating with the right pleural space. Despite repeated thoracenteses, rapid reaccumulation necessitated chest tube placement. Interval chest imaging after discharge showed resolution of pleural effusion with subsequent removal of pancreatic stent. This case underscores the importance of considering right-sided PPF in patients with acute pancreatitis presenting with massive or recurrent right pleural effusions.