Warren Alpert Medical School of Brown University Providence, RI
Firrah Saeed, MD1, Jason T. Tsichlis, MS1, Christopher Ward, MD1, Sarah M. Hyder, MD, MBA2; 1Warren Alpert Medical School of Brown University, Providence, RI; 2Brown University, East Providence, RI
Introduction: Fistula formation is a known complication of chronic pancreatitis, which arises from indirect pseudocyst communication or ductal disruption. Pancreaticopericardial and pancreaticopleural fistulas are rarer and their management is often nebulous. These fistulas develop posteriorly into the retroperitoneal space through the aortic or esophageal hiatus leading to retroperitoneal ductal disruption. Fistulous tracts into the mediastinum increase risk for mediastinitis.
Methods: A 55-year-old-male with recurrent alcoholic pancreatitis presented with sharp right sided chest pain and epigastric discomfort. CT revealed multiple pancreatic cysts with pancreaticopleural and pancreaticopericardial fistulas, a pericardial effusion, and loculated pleural effusions. Transthoracic echocardiogram revealed septated pericardial effusion without tamponade. EUS confirmed pancreas cysts with obvious tract to the mediastinum. Standard treatment for acute on chronic pancreatitis occurred. Management of fistulizing disease was more nuanced and involved multiple specialties. To allow downstream drainage of the pericardial effusion, interventional radiology placed an abdominal drain. After initial improvement, patient reported vomiting and chest pain, found to be septic secondary to posterior mediastinitis. Chest tubes were placed; pleural fluid analysis revealed high amylase and lipase. Next, ERCP revealed active pancreas duct leak; a pancreatic sphincterotomy was performed and pancreatic duct stent was placed. The patient was started on IV octreotide. Currently, patient remains clinically stable with plan for repeat endoscopic evaluation of pancreatic duct leak. Discussion: Chronic pancreatitis causes varying long term sequelae; severe complications arise due to pancreas duct disruption and fistulous tract formation. Standard management includes endoscopic drainage; surgery is pursued if endoscopic management fails. Pancreatic stent placement to reduce flow through fistulous tracts has been associated with 85-100% success rates. Conservative approaches lead to fistula closure rates in up to 50% of cases. Octreotide is used to slow fistula output. Placement of chest tubes can be beneficial for pleural effusions, and pericardiocentesis and pericardial drains are reserved for patients with tamponade. Mediastinitis can be a fatal complication of unresolved disease, and may present with sepsis. Complicated fistulous disease in pancreatitis requires a multi-specialty approach to reduce mortality.
CT abdomen with contrast (coronal view) demonstrating fistulous connection between pancreatic pseudocyst and the pericardium
Disclosures: Firrah Saeed indicated no relevant financial relationships. Jason Tsichlis indicated no relevant financial relationships. Christopher Ward indicated no relevant financial relationships. Sarah Hyder indicated no relevant financial relationships.