Pancreatic fistula is an abnormal connection between the pancreas and another organ or space caused by leakage of pancreatic enzymes. It is usually associated with pancreatitis and treated with food restriction, somatostatin analogues, and surgery. There are two types: external and internal. Diagnosis is made by analysis of fluid and CT scans, and treatment includes no oral food intake, total parenteral nutrition, and endoscopic or surgical treatment.
A pancreatic fistula refers to an abnormal connection between the pancreas and another organ or space caused by the leakage of potent pancreatic enzymes from the damaged pancreatic duct or by a pancreatic pseudocyst. It usually occurs in association with pancreatitis but can also be a complication of surgical manipulation or abdominal trauma. This condition is usually treated by restriction of food intake, administration of somatostatin analogues and, in the worst cases, surgical or endoscopic treatment.
There are two main types of pancreatic fistula. The first is called an external pancreatic fistula, or pancreaticocutaneous fistula, so called because of the abnormal communication between the pancreas and the skin. Pancreatic secretions are rich in bicarbonate, a substance that helps maintain the normal hydrogen potency (pH) of the blood. When a pancreaticocutaneous fistula occurs, bicarbonate-rich secretions evaporate, leading to acidosis or a decrease in blood pH.
The second type is called an internal pancreatic fistula because the pancreas communicates with other organs or intra-abdominal spaces. When pancreatic secretions enter the peritoneal cavity, they are called pancreatic ascites. If the mediastinum or central thoracic compartment is affected, this is referred to as enzymatic mediastinitis. In cases where the pleural coverage of the lungs is affected, it is referred to as pancreatic pleural effusion or pancreatico-pleural fistula.
Pancreatitis, or inflammation of the pancreas, is the most common precedent of pancreatic fistula. Acute pancreatitis results from excessive alcohol intake and gallbladder disorders such as gallstones. Chronic pancreatitis commonly results from alcoholism in adults and is linked to abdominal trauma in children. Traumatic injury to the pancreas is rare because the pancreas is relatively protected by its retroperitoneal location. An important but uncommon precedent is pancreatic surgery for malignancy or necrotizing pancreatitis.
Diagnosis of a pancreatic fistula is made by analysis of the fluid within the pleura or abdominal cavity. When the level of amylase, a pancreatic enzyme, is above 1,000 international units (IU) per liter and the pancreatic protein level is above 3.0 g/dL, the diagnosis is confirmed. Computed tomography (CT) with contrast can help locate the fistula. A useful diagnostic procedure for biliary tract disorders, called endoscopic retrograde cholangiopancreatography (ERCP), can also aid in the diagnosis.
Treatment of a pancreatic fistula is challenging because pancreatic enzymes are required for the digestion of food taken by mouth. Guiding principles include no oral food intake, total parenteral nutrition, and administration of somatostatin analogs such as octreotide, which is supposed to inhibit pancreatic secretion. Endoscopic treatment via ERCP and placement of a stent or drain can be done to reduce pressure in the pancreatic duct. If conservative and endoscopic treatments fail, surgical treatment by pancreatic resection or pancreatic duodenectomy can be performed.
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