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Blunt Costophrenic Angle in a Patient with Pancreatitis


Am Fam Physician. 2021 May 15;103(10):625-627.

A 40-year-old patient presented with new-onset abdominal pain, nausea, and vomiting. The patient did not have fever, diarrhea, or changes in bowel movements. The medical history included hypertension, anxiety, obstructive sleep apnea, and recurrent pancreatitis complicated by pancreatic necrosis secondary to chronic alcohol abuse.

Initial laboratory findings included elevated lipase and mildly elevated triglyceride levels consistent with recurrent pancreatitis. The patient was admitted for initiation of intravenous fluids, nutritional support, and pain management but was transferred to a tertiary care center after developing a fever, shortness of breath, and a need for supplemental oxygen. Physical examination revealed diminished breath sounds at the right lung base. Chest radiography was obtained (Figure 1).




Based on the patient's findings, which one of the following is the most likely diagnosis?

  • A. Chylothorax.

  • B. Hemidiaphragm paralysis.

  • C. Lobar pneumonia.

  • D. Pleural effusion.

  • E. Subphrenic pancreatic pseudocyst.


The answer is E: subphrenic pancreatic pseudocyst. The chest radiograph showed a large right-sided pleural effusion and blunting of the costophrenic angle. Point-of-care ultrasonography performed in preparation for thoracentesis did not reveal any appreciable pleural effusion. A subsequent computed tomography (CT) scan of the chest, abdomen, and pelvis (Figure 2) demonstrated a loculated, complex, proteinaceous fluid collection measuring 14 cm × 13 cm × 12 cm (estimated volume = 1,100 mL) in the right subphrenic space, which was compressing the right liver lobe and surrounding structures. Fluid obtained through fine-needle aspiration guided by endoscopic ultrasonography showed very high amylase content and a low carcinoembryonic antigen level, which are consistent with a pancreatic pseudocyst.

Address correspondence to Joel Amidon, MD, at Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


show all references

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7. Rudrappa M, Paul M. Chylothorax. StatPearls. Updated January 25, 2021. Accessed March 27, 2021.

8. McCool FD, Tzelepis GE. Dysfunction of the diaphragm [published correction appears in N Engl J Med. 2012; 366(22):2138]. N Engl J Med. 2012;366(10):932–942.

9. Kaysin A, Viera AJ. Community-acquired pneumonia in adults: diagnosis and management [published correction appears in Am Fam Physician. 2017;95(7):414]. Am Fam Physician. 2016;94(9):698–706. Accessed March 25, 2021.

10. Saguil A, Wyrick K, Hallgren J. Diagnostic approach to pleural effusion. Am Fam Physician. 2014;90(2):99–104. Accessed March 25, 2021.

This series is coordinated by John E. Delzell Jr., MD, MSPH, associate medical editor.

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