Eastern Virginia Medical School Norfolk, VA, United States
Byung S. Yoo, MD, Ana R. Vilela, MD, Parth J. Parekh, MD Eastern Virginia Medical School, Norfolk, VA
Introduction: The formation of fistulas to other viscera as a complication of pancreatic pseudocyst (PP) is rare. We present a case of acute pancreatitis complicated by a fistula between an infected PP and the bile duct.
Case Description/Methods: 30-year-old male with history of alcohol abuse presented with acute pancreatitis (AP) and a peripancreatic fluid collection thought to represent a PP. He was conservatively managed and was discharged with follow up. Two weeks later, he returned with worsening abdominal pain and nausea although he remained abstinent from alcohol. CT imaging showed an enlarged PP, measuring 14 x 12cm and evidence of intrahepatic biliary duct dilation. (Figure 1A) Cholangiogram revealed extravasation of contrast originating from the left main hepatic duct to the PP suggestive of a fistula (Figura 1B). A biliary sphincterotomy was performed and stent placed at the take-off of the left hepatic duct. Next, endoscopic ultrasound (EUS) revealed a 5.3 x 7.3cm cystic lesion at the level of the pancreatic body, and fine needle aspiration was performed demonstrating purulent fluid. Finally, an EUS-guided cystogastrostomy was created utilizing a lumen apposing metal stent. Cyst fluid studies were significant for amylase of 3,443 U/L and CEA of 5.4 ng/ml, and the fluid cultures grew Streptococcus mitis/oralis and Klebsiella pneumonia. Patient tolerated the procedure well without any complications. He received octreotide and completed a course of antibiotics with Cefazolin. The pre-existing stents in the biliary tree and pancreatic duct were removed after 3 months with cholangiogram demonstrating resolution of fistula. (Figure 1C).
Discussion: Fistulous communication between a PP to the biliary tree is extremely rare. The management of this condition is not yet fully defined as there are very few reported cases treated either surgically, via percutaneous external drainage, or via endoscopic ultrasound guided drainage and biliary stenting. In our case, we successfully managed a large, infected PP that fistulized to the intrahepatic ducts by placing biliary and pancreatic stents, an EUS-guided cystogastrostomy, administering octreotide and the appropriate antibiotics. This case highlights potential serious complications of PP and the importance of the expertise in successfully treating the complication.
Figure: Figure 1: 1A. Coronal CT showing PP measuring 14 x 12cm and evidence of intrahepatic biliary duct dilation. 1B. ERCP showing extravasation of contrast from the left main hepatic duct to the PP indicating biliary fistula. 1C. Repeat ERCP after biliary and pancreatic stents removal showing fistula resolution.
Disclosures: Byung Yoo indicated no relevant financial relationships. Ana Vilela indicated no relevant financial relationships. Parth Parekh indicated no relevant financial relationships.
Byung S. Yoo, MD, Ana R. Vilela, MD, Parth J. Parekh, MD. P0092 - A Bizarre Connection in an Alcoholic Patient: Pancreatic Pseudocyst With Fistula to the Bile Duct, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.