Pancreaticoureteral Fistula: A Rare Complication of Pancreatitis

Abstract

Introduction: Pancreatitis is an inflammatory condition that can cause progressive and permanent destruction of the pancreas, which can lead to exocrine and endocrine insufficiency. There are many other complications associated with pancreatitis including formation of pseudocysts, pancreatic ascites, pleural effusions, splenic or portal vein thrombosis, pseudoaneurysm of splenic artery, and pancreatic fistulas. This case report describes an uncommon formation of a pancreaticoureteral fistula as a result of pancreatitis. Case Report: A 69-year-old Hispanic female with past medical history significant for recurrent episodes of pancreatitis with pseudocyst formation presented to emergency department with a chief complaint of sharp, severe, constant abdominal pain associated with nausea and a few episodes of non-bloody, non-bilious vomiting. Her last episode of acute pancreatitis was 2 months ago. Vital signs were normal. Physical examination revealed mild tenderness in the left upper and left lower quadrant without any guarding or rigidity. A computed topography (CT) scan of abdomen was performed which showed an abnormal pancreatic duct in the body and tail of the pancreas with complex multiloculated pseudocyst within the body and tail of the pancreas, extending anteriorly into the lesser sac to the stomach, posteriorly and medially extending into the level of the left kidney with possible fistula formation with mild left-sided hydronephrosis. To evaluate the presence of the fistula, the patient underwent cystoscopy with a left retrograde pyelogram which confirmed the presence of a fistula connecting the left renal pelvis to the pancreatic duct. A ureteral stent was placed at that time to facilitate closure of the fistula. Despite ureteral stent placement, the patient’s symptom did not improve so she underwent an endoscopic retrograde cholangiopancreatography (ERCP) with pancreatic duct stent placement. The patient remained symptomatic and ultimately underwent pancreatic cyst gastrostomy. Post-procedure, the patient improved and a repeat left retrograde pyelogram showed resolution of the pancreaticoureteral fistula. Conclusion: Pancreatic fistulas are rare complications of pancreatitis. Diagnosis can be made by imaging modalities such a CT, MRCP, ERCP, fistulography, etc. Treatment is conservative medical management; however, patients may need endoscopic or surgical intervention. Keep this rare complication in mind when evaluating a patient presenting with pancreatitis and urinary complaints.