Spontaneous pancreaticorenal fistula

Abstract

A 28-year-old woman presented with a 3-month history of pain in the left upper abdomen that radiated to the left shoulder. Laboratory test results included a white blood cell count of 11,000/mm3 (normal: 4300-10,200/mm3). CT demonstrated a subcapsular fluid collection involving the left kidney that compressed the renal parenchyma and was in contact with the spleen, and a pseudocyst near the tail of the pancreas (A). A communication between these structures suggested the diagnosis of a pancreaticorenal fistula (A, arrow). The diagnoses were confirmed at open laparotomy, at which left renal capsulotomy and drainage of the pseudocyst were performed with placement of an external drain. Drainage persisted despite total parenteral nutrition and treatment with octreotide, and a decision was made for endoscopic treatment. Endoscopic retrograde pancreatography demonstrated a normal-appearing main duct in the head and body of the pancreas, another communicating pseudocyst near the body of the pancreas (B, arrowhead), irregular stenoses of the main duct in the tail and leakage of contrast into the retroperitoneal space with flow into the external drain (B, arrow). A pancreatic duct stent was inserted, and a pancreatic sphincterotomy was completed over the stent. At ERCP 1 month later, the main duct was dilated to 8 mm, with strictures in the body and tail (C, arrows). Ectatic changes were evident in the main duct branches, but the fistulous tract was closed. The stent was not replaced, and the external drain was removed. CT demonstrated resolution of the pseudocyst and subcapsular renal fluid, together with an enlarged tail of the pancreas and thickening of the left anterior renal fascia (D). View Large Image Figure Viewer View Large Image Figure Viewer View Large Image Figure Viewer