Pancreatogastric Fistula: A Rare Complication of Pancreatitis

Abstract

Pancreatic pseudocysts complicate the course of chronic pancreatitis in 30-40% of patients. In acute pancreatitis, pseudocyst formation is seen in 6 to 18.5% of patients. Walled-off pancreatic necrosis (WOPN) can follow the development of a pseudocyst. Fistulization and spontaneous perforation occur in fewer than 3% of pseudocysts. Of the rare cases of fistula formation, pacreatocolonic fistulas are the most common, while pacreatogastric fistulas are the most rare. A 46 year old male with a history of alcohol abuse was seen in the gastroenterology clinic for epigastric pain, nausea, vomiting, early satiety, and weight loss. The patient had been hospitalized 6 weeks prior for acute alcoholic pancreatitis. During that admission, initial CT scan of the abdomen with contrast revealed a diffusely edematous and enlarged pancreas with a large amount of peripancreatic edema. On hospital day 7, CT angiography of the chest ordered due to hypoxia showed moderate-sized bilateral pleural effusions as well as increased peripancreatic inflammation with a moderate amount of fluid along the left lateral margin of the stomach. No pseudocyst or abscess was noted. He clinically improved over the next few days and was discharged. In the gastroenterology clinic, he endorsed continued daily emesis since his hospital stay with blood streaked vomitus. EGD and CT scan of his abdomen and pelvis with contrast was ordered. Due to scheduling, EGD was performed first and noted diffuse inflammation through the stomach, increased in the pylorus, with a small fistula in the antrum. CT scan later confirmed a fistulous connection from the area of a large pancreatic WOPN to the posterior wall of the gastric antrum with surrounding gastritis and duodenitis. He was referred and seen by advanced endoscopy less than 2 weeks later and was doing remarkably well without intervention required. Complications can be quite common in acute or chronic pancreatitis. Supportive care of fistula formation with correcting malnutrition and electrolytes has shown closure rates from 50-80%. If persistent, pancreatic stent placement has shown success rates from 85-100%. Understanding the different types of pancreatic complications and how to manage them is a necessity for gastroenterology providers.