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GASTROINTESTINAL FISTULAE IN ACUTE PANCREATITIS: SINGLE CENTER EXPERIENCE
Bipadabhanjan Mallick*1, Narendra Dhaka1, Jayanta Samanta1, Raghavendra Prasad1, Neha Berry1, Saroj Sinha1, Vikas Gupta2, Thakur D. Yadav2, Rakesh Kochhar1
1gastroenterology, postgraduate institute of medical education and research, Chandigarh, Chandigarh, India; 2general surgery, postgraduate institute of medical education and research, Chandigarh, Chandigarh, India
BACKGROUND: Gastrointestinal tract (GI) fistulzation occurs rarely in the clinical course of acute pancreatitis (AP). Hence, data is lacking regarding the natural history of these fistulae.
AIM: To evaluate the prevalence, clinical course, outcome and prognostic factors associated with GI fistulization in AP.
METHODS: Records of all patients of acute pancreatitis from 2006 - 2015 were analysed retrospectively for the occurrence of fistulzation into GI tract. All patients with GI fistulae were studied further for demographic characteristics, clinical presentation, time interval between pancreatitis and development of fistulae, diagnostic studies, treatment (including surgery), and outcome.
RESULTS: Of 1079 patients of acute pancreatitis, GI fistulization was detected in 62 patients (mean age 39.03±12.2 years; 55 males) with a prevalence of 5.7%. Alcohol was the major etiology in 44 (71%) followed by gall stones in 12 (22.5%), idiopathic in 4 (6.4%) and trauma in 2 (3.2%) patients. The time duration between onset of AP and detection of fistulae was 5.84 ± 5.2 weeks. The most common feature was persistent fever in 35 (56.5%), followed by GI bleed in 21 (33.9%) and pain abdomen in 14 (22.6%) patients. Fistulae developed spontaneously in 34 (55%) patients, while the rest 28 (45%) had history of either surgical or percutaneous intervention. The most common site of fistulous communication was colon 25 (40%), followed by duodenum in 24 (39%), small bowel in 6 (9.7%), stomach in 5 (8.1%) and both colon and duodenum in 2 (3.2%).CECT abdomen (n=40) raised suspicion of fistulae (air foci within the necrotic collection) in 47.5%% and by inflammatory involvement of the bowel in 15 %, while only necrosis was seen in 27.5% of patients. Out of 27 patients, who underwent endoscopy, 23 (85%) had direct visualization of the fistulous communication, while 4 (15%) had edematous inflamed mucosa. Additionally 14 patients underwent fistulogram to confirm the communication. Treatment included surgical intervention in 31 (50%), conservative management in 16 (25.8%), endotherapy in 12 (19.4%) and percutaneous intervention in 3(4.8%). Overall mortality was 15 (24.2%). The need for surgical intervention (p=0.008) and mortality (p=0.003) were significantly higher in colonic than upper gastrointestinal fistulae.
CONCLUSION: Development of GI fistula in patients with acute pancreatitis is an ominous and uncommon complication requiring high index of suspicion. Colonic location is associated with higher requirement of surgical intervention and higher mortality.
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