Zarir Ahmed, DO1, Ahmad M. Al-Taee, MD2, Christine Boumitri, MD1
1St. Louis University, St. Louis, MO; 2Saint Louis University, St. Louis, MO
Introduction: Pancreatic fistulas have been described in the setting of pancreatic resection, trauma, and less commonly in acute or chronic pancreatitis (CP). Spontaneous pancreatic fistulas resulting in gastrointestinal (GI) bleeding are rare.
Case Description/Methods: An 80 year-old woman presented to the emergency room with shortness of breath and melena. She was afebrile, normotensive, and had a heart rate of 93. Labs showed hemoglobin (Hgb) of 5.2 g/dL. EGD showed a 2 mm clean-based duodenal ulcer. As this did not account for melena, she had a colonoscopy and video capsule endoscopy which did not show a clear source of bleeding. As she continued to have melena with drop in Hgb, she had an abdominal CT scan showing a retroperitoneal fluid collection medial to the 2nd and 3rd portions of the duodenum, hyperattenuating material in the 2nd portion of the duodenum concerning for bleeding, and signs of CP with a pancreatic duct (PD) diameter of 14 mm. A second look EGD showed a duodenal mucosal defect suspicious for a fistulous opening into the PD with evidence of active bleeding (figures 1 and 2). Repeat CT scan revealed extraluminal contrast extravasation into the retroperitoneum medial to the 2nd part of the duodenum and close in proximity to the superior mesenteric vein (SMV) (figure 3). Abdominal MRI showed signs of CP and multiple small pseudocysts in the body and tail. Patient’s melena resolved and Hgb stabilized prior to discharge.
Discussion: Bleeding is a rare complication of CP and occurs in 10-15% of CP patients. Pancreatic structures can be destroyed by enzyme digestion and necrosis. This may create pseudoaneurysms which may create cavities, fistulas, or rupture if they involve arterial or venous structures. The splenic and gastroduodenal artery are most commonly involved. Clinical presentation varies depending on location and severity of bleeding. Diagnosis involves abdominal CT and EGD, however laparotomy may sometimes be needed. Management involves embolization or surgery.Our patient’s pancreaticoduodenal fistula was the result of previously undiagnosed CP. Bleeding may have resulted from spontaneous hemorrhage into the cystic cavity or as a result of erosion into the SMV given proximity on imaging. This case highlights the need to maintain a high clinical suspicion for pancreaticoduodenal fistulas in patients with a history of pancreatic disease presenting with GI bleeding.
Citation: Zarir Ahmed, DO; Ahmad M. Al-Taee, MD; Christine Boumitri, MD. P0087 - BLEEDING PANCREATICODUODENAL FISTULA: AN UNUSUAL CASE OF MELENA. Program No. P0087. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.