S1567 Pancreatico-Pleural and Enteric Fistulas: A Rare Complication of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis

Abstract

INTRODUCTION: Pancreatico – pleural and enteric fistulas (PPEF) are rare complications of pancreatitis, where a tract is created draining pancreatic fluid into the pleural cavity and/or bowel. Endoscopic retrograde cholangiopancreatography (ERCP) is associated with a 5-10% risk of pancreatitis. CASE DESCRIPTION/METHODS: A 66-year-old female with past medical history of hypertension and asthma presented for abdominal pain with nausea and vomiting. One-day prior she underwent an ERCP. She was treated conservatively for post-ERCP (pERCP) pancreatitis. Subsequently she was admitted for pancreatitis three times over a period of 3 months. Vitals were within normal limits. Physical examination was significant for diffuse abdominal tenderness and normoactive bowel sounds. Laboratory data was significant for a lipase of 2858, and a WBC of 12.39. Otherwise, complete metabolic panel, and CBC were normal. Initial computerized tomography (CT) showed acute pancreatitis with a large pseudocyst (Figure 1). Interval CT showed pancreatic duct dilation, a pancreatico-enteric fistula tract and a new left pleural effusion with air within the fluid suggestive of a pancreatico-pleural fistula (Figure 2). The patient was managed conservatively. At 3-month follow up, the patients symptoms had resolved, and a repeat CT showed resolution of pancreatitis, fistula and pleural effusion (Figure 3). DISCUSSION: Magnetic resonance cholangiopancreatography is the diagnostic imaging of choice for visualizing pancreatic fistulas. Thoracentesis with a lipase-rich pleural fluid can help aid in the diagnosis.Modalities of treatment are endoscopic stenting of the disrupted pancreatic duct, conservative management with octreotide (to suppress pancreatic exocrine function) with or without chest tube drainage, or surgical intervention with distal pancreatectomy and pancreatico-jejunostomy in those with complete ductal obstruction. Thirty to 60% of patients can be managed successfully with conservative management. Sphincter of oddi dysfunction, young age, repeated cannulation attempts with sphincterotomy, and history of pancreatitis are risk factors for pERCP pancreatitis. Prophylactic rectal indomethacin and pancreatic stenting in patients at high risk of pERCP pancreatitis have been shown to decrease incidence rates. PPEF uncommonly arise together and require a high index of suspicion. The diagnosis can be made via imaging, endoscopy or with a thoracentesis. Management is usually conservative, but endoscopic or surgical procedures may be warranted.Figure 1.: CT abdomen and pelvis showing acute pancreatitis with a pancreatic tail/body large pseudocyst (Green arrow).Figure 2.: Interval CT Chest, abdomen and pelvis showing dilated pancreatic duct (Blue arrow), resolving pancreatic pseudocyst(White arrow), pancreatico-enteric fistula tract (Red arrow), and a new left pleural effusion with air within the fluid (Yellow arrow) suggestive of a pancreatico-pleural fistula.Figure 3.: A 3-month Interval CT abdomen, pelvis and chest showing complete resolution of acute pancreatitis and fistula tract (Panel A), and resolution of pleural effusion (Panel B).