1421 Pancreaticocolonic Fistula: A Rare Cause of Recurrent Infective Endocarditis

Abstract

INTRODUCTION: Pancreatic fistulas to adjacent organs may develop as a result of severe pancreatitis and pancreatic cystic lesions, which can lead to infectious complications. The aim of this case is to recognize pancreaticocolonic fistula (PCF) as an unusual cause of persistent infection such as infective endocarditis (IE). CASE DESCRIPTION/METHODS: 59-year-old male with a history of chronic alcoholic pancreatitis, recurrent mitral valve IE (Proteus, Morganella and Enterococcus species), end stage renal disease, and heart failure (HF) was admitted after a fall. Initial labs showed almost 2 g drop in baseline hemoglobin (9.8 to 8.1 g/dL). Non-contrasted computed tomography (CT) of abdomen to assess for retroperitoneal bleed revealed a 1.3 × 1.6 cm air-filled cavity at the pancreatic tail communicating with the colonic splenic flexure in addition to moderate ascites. Contrasted CT showed similar findings (Figure 1), suggestive of a PCF. Ascites fluid analysis was consistent with a transudative process (attributed to HF) with amylase <10. An endoscopic ultrasound with fine needle aspiration for a pancreatic tail cyst two years prior revealed a hemorrhagic cyst. A colonoscopy two years ago showed 13 polyps up to 1 cm in size with histology consistent with tubular adenomas and tubulovillous adenomas. Given concern for colonic pathology as a nidus of the PCF, a colonoscopy was pursued. This revealed a small fistulous opening (Figure 2) 45 cm from the anal verge, which was closed with a clip. There was no evidence of malignancy. The PCF was thought to be the sequela of recurrent pancreatitis with cyst formation eroding into the colonic wall, resulting in recurrent polymicrobial bacteremia and IE. Endoscopic retrograde cholangiopancreatography (ERCP) with pancreatic sphincterotomy and pancreatic stent placement is planned. Repeat culture data on broad-spectrum antibiotics has remained negative. DISCUSSION: PCF is a rare complication of severe acute necrotizing pancreatitis with a high mortality rate. Surgery is the main treatment modality, but conservative and endoscopic management are alternative options in non-surgical candidates. Our patient was deemed high surgical risk. Conservative management includes nutritional support (preferably enteral), electrolyte repletion, broad-spectrum antibiotics, somatostatin analogues, and percutaneous drainage. Endoscopic treatment with ERCP and subsequent pancreatic sphincterotomy and pancreatic duct stenting lead to fistula closure in many cases.