Pancreatico-gastric Fistula

A 43-year-old man presented to the emergency department with syncope following hematemesis. He gave the history of melena for 3 days. His Hb was 5.6 gm/dl. After initial resuscitation, UGI endoscopy revealed a soft volcano-like lesion along lesser curvature posteriorly in mid corpus that was oozing blood from a papilla-like structure (Figure 1) which was intermittently releasing blood. CT with contrast revealed a Pancreatico-gastric fistula from a cystic lesion in an atrophied pancreas (Figure 2) due to chronic pancreatitis. EUS was done and showed a cystically dilated main pancreatic duct with a possible blood clot distal to the neck of the pancreas (Figure 3), causes such as retention cyst, malignancies, and hemosuccus pancreaticus were considered. Fine needle aspiration yielded cola-colored fluid which was sent for analysis. He was also noted to have splenic vein thrombosis associated with sinistral Portal hypertension (secondary to chronic pancreatitis), distal pancreatectomy with or without splenectomy was advised. The patient refused treatment and has since traveled abroad for further management (lost to follow-up).

A pancreatic fistula is an abnormal connection between the pancreatic ductal epithelium and another epithelium surface. This is due to a disruption of the pancreatic duct leading to the pancreatic fluid leaking, producing erosion, and forming different pathways resulting in internal and external pancreatic fistulas. Causes of pancreatic fistulas can be iatrogenic or non-iatrogenic [1]. Non-iatrogenic causes include abdominal trauma, acute pancreatitis, and chronic pancreatitis [1,2]. Internal fistulae can form because of the rupture of pseudocysts or abscesses into adjacent organs such as the stomach or pleural cavity [3]. Of the rare cases of fistula formation, pancreato-colonic fistulas are the most common, while pancreato-gastric fistulas are the rarest [4].

Footnote

The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Ethical Considerations were undertaken and the patient’s consent was obtained.

1. Unegbu FC, Anjum F. Pancreatic Fistula. [Updated 2023 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024. https://www.ncbi.nlm.nih.gov/books/NBK560871/
2. Larsen M, Kozarek R. Management of pancreatic ductal leaks and fistulae. J Gastroenterol Hepatol. 2014;29(7):1360-70. doi: 10.1111/jgh.12574. PMID: 24650171.
3. Tseng CW, Tsai JJ, Chen CC. Education and imaging. Hepatobiliary and pancreatic: Pancreatic fistula. J Gastroenterol Hepatol. 2009 Feb;24(2):325. doi: 10.1111/j.1440-1746.2008.05766.x. PMID: 19215340.
4. Ryan J, Gerald M, Nathaniel K. Pancreatogastric Fistula: A Rare Complication of Pancreatitis: 1247. American Journal of Gastroenterology 113: S716, https://journals.lww.com/ajg/fulltext/2018/10001/pancreatogastric_fistula__a_rare_complication_of.1247.aspx