3035 Pancreatico-Vesical Fistula

Abstract

INTRODUCTION: Acute pancreatitis is an important cause of acute abdomen. It involves peripancreatic tissues or even remote organs or organ systems due to the enzyme rich fluid of pseudocyst. Here we report a case where acute pancreatitis resulted in a fluid collection that tracked down to the pelvis and spontaneously drained into the urinary bladder via a pancreatico-vesical fistula. CASE DESCRIPTION/METHODS: A 28-year-old male, chronic alcoholic, developed epigastric pain for last 4 days which radiated to the back with raised serum lipase and amylase levels. He was started on conservative therapy for acute pancreatitis and took discharge against medical advice but returned again 3 weeks later with severe pain in epigastrium as well as left flank, which is boring. Abdominal tenderness and muscle guarding were elicited. Diminished bowel sounds. CT abdomen: a bulky pancreas with non-enhancing areas, peripancreatic stranding, and acute fluid collections involving the body and tail of the pancreas extending along the renal fascia toward the pelvis and resting on the left superolateral wall of the urinary bladder. The epigastric pain gradually improved with complaints of burning micturition 2 days after without pyelonephritis signs. The urine had brownish tinge, turbid, foul smelling and microscopy revealed no bacteria/casts. An abdominal sonogram: normal kidneys but thickened UB wall with thick mobile echoes lying on left superolateral UB. Urine lipase and amylase were 499 U/Lit and 350 IU/Lit. CT cystography: contrast leakage from the left superolateral UB wall into the perivesical with fluid-fluid level seen in the UB suggestive of contrast –debris level means pancreatic-vesical fistula. Stenting of the pancreatic duct and percutaneous drainage of the fluid collection are done with regression of urinary symptoms and urinary amylase. 12 days after a repeat cystogram showed spontaneous healing of the fistula. The patient was followed up for 5 months with free of symptoms. DISCUSSION: Inappropriate activation of pancreatic proenzymes causes acute pancreatitis. It digests the pancreatic parenchyma, the peripancreatic tissues, leads to arterial pseudoaneurysms, fat necrosis and bowel perforation. Pseudocyst can communicate with the pleura, peritoneum, and gut or to the skin surface. Pancreatic fistulas to the urinary tract are rare and such fistulas usually communicate with the left kidney. Urinary amylase levels can thus be monitored.