Abstract
INTRODUCTION: Pancreaticoenteric fistulas are a rare complication of acute pancreatitis. Spontaneous fistulation has been described in the literature in cases where acute pancreatitis is complicated with infection or necrosis. As a direct consequence to the fistula formation, direct vascular injury may occur, resulting in blood loss and rapid clinical deterioration. CASE DESCRIPTION/METHODS: A 77-year-old male with past medical history of essential hypertension, type 2 diabetes mellitus and coronary artery disease status post coronary artery bypass grafting in 2017 was brought to Emergency Room due to sudden onset right leg pain. He was admitted due to subacute limb ischemia and started on antiplatelet and anticoagulation medical therapy. Hospital course complicated with abdominal pain and four episodes of large volume port wine stools per rectum and significant drop in hemoglobin levels. After initial resuscitation measures, which include intravenous hydration and supportive blood products transfusions, patient was consulted to Gastroenterology service for evaluation and recommendations. Esophagoduodenoscopy revealed large clean base ulcerated lesion with an associated fistulous process in the first portion of the duodenum. No active bleeding nor blood remnants were noted. Abdominopelvic CT scan was immediately done and showed extensive devitalization of the pancreas along with large peripancreatic fluid collection with abundant internal gas suggestive of a contained perforation of duodenum. Interventional radiology and General surgery was consult. DISCUSSION: Spontaneous pancreaticoenteric fistula in the setting of pseudocysts formation secondary to necrotizing pancreatitis is a very rare and unique complication. Typical management is conservative, with medical therapy resulting in closure of the vast majority of fistulas. The infrequency with which pancreaticoenteric fistulas are encountered makes them a formidable diagnostic and treatment challenge. Even though it has been described in the literature, there still much to investigate regarding upper gastrointestinal fistulas and its associated vascular complications after acute pancreatitis.
Published Version
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