Byung Soo Yoo, MD, Maurice Marcuard, MD, Parth J. Parekh, MD; Eastern Virginia Medical School, Norfolk, VA
Introduction: Pancreatic pseudocysts are a complication of acute pancreatitis, and they can often fistulize with surrounding organs. We present a rare case of necrotizing pancreatitis complicated by a pancreatico-colonic fistula.
Methods: 32-year-old female with ongoing alcohol abuse presented with fever and worsening abdominal pain. Imaging demonstrated acute pancreatitis complicated by an infected pseudocyst for which she underwent an EUS with creation of a cystogastrostomy using a lumen apposing metal stent (LAMS). Cultures grew Candida albicans, and she was discharged with 4 weeks of fluconazole. Subsequently, she underwent completion transgastric direct endoscopic necrosectomy with removal of her LAMS. One week following necrosectomy, she presented with fever, chills, and left sided flank pain radiating to back. She reported compliance with her medications and abstinence from alcohol. Her blood work was significant for WBC of 11.3 K/mL, lactic acid of 2.8 mmol/L, procalcitonin of 2.2 ng/mL, lipase of 87 U/L (60 U/L is upper limit of normal), and ALT, AST, alkaline phosphatase of 24, 43, and 220 U/L respectively. Subsequent imaging demonstrated acute necrotizing pancreatitis with an interval increase in size of the pseudocyst, measuring 5.9 x 5.2 x 6.1 cm. (Figure 1) With these findings, she was started on antibiotics and scheduled for an EUS. EUS was performed with creation of a cystogastrostomy using a LAMS with purulent evacuate. (Figure 2) The pseudocyst was then intubated and irrigated, during which, a fistula was discovered to be connected to the descending colon. (Figure 3) Given the findings, general surgery was consulted and she underwent partial colectomy with primary anastomosis. She tolerated the surgery well, resumed regular diet, and was discharged. The pre-existing cystogastrostomy stent was removed after 3 weeks and she has continued to do well.
Discussion: Pancreatic pseudocyst develops in upwards of 18% in patients with acute pancreatitis and 40% in chronic pancreatitis. Direct fistulous communications to the colon or pancreatico-colonic fistulas are a rare and possibly fatal complication with a mortality rate up to 67%, commonly due to bleeding and sepsis. The key management includes drainage for infection control, antibiotics, and early surgical or endoscopic evaluation and intervention. This case highlights potential serious complications of pancreatic pseudocyst and the necessity of a multi-disciplinary approach to these complex patients.