Pancreatic Pseudo-cyst Formation Resulting in Bilateral Duodenal and Colonic Fistulas: 689

Purpose: Pancreatic pseudocysts are one of the common complications of acute and a chronic pancreatitis and have variable outcome pending the patient's other preexisting conditions. Many means of pseudocyst decompression have been proposed but one that has not been described fully is spontaneous fistulization into the gastrointestinal tract. It has been estimated that up to 5% of pseudocysts spontaneously rupture with up to 50% directly into the peritoneum. Many case reports report one draining fistula; however, we present a case of a patient who was found to not have one, but two spontaneously draining pancreatic fistulas into different areas of the gastrointestinal tract. Methods: A 59-year-old male presented to the emergency room with complaints of fever, diarrhea and vomiting. The patient's past medical history was significant for hypertension, hyperlipidemia, Hepatitis C, CVA, cirrhosis, alcohol abuse and upper GI bleeds. The patient's surgical history was significant for a pacemaker placement and ERCP with stent placement. The patient was recently discharged for organized necrotizing pancreatitis, cholangitis, rapidly progressing glomerulonephritis and Enterobacter bacteremia. The patient had developed a pancreatic pseudocyst that spontaneously fistulized and drained into the head of the pancreas into the duodenal bulb. The patient after a long course and stabilization was discharged afebrile. Several days later, the patient returned again to the hospital with aforementioned complaints. He then underwent a colonoscopy which demonstrated an area of focal thickening and inflammation in the descending colon that corresponded to a fistula with the tail of the pancreas. .035 inch guidewire was used to probe the fistula and a tract was discovered that surpassed 7-8 cm of the wire. The patient was then diagnosed as a focal colitis secondary to a second pancreatic fistula. Results: Pseudocyst drainage occurs because of enzymatic digestion of the cyst wall; careful attention must be paid as these cysts can also fistulize with vessels and cause gastrointestinal hemorrhage. Special attention should be paid to the endoscopic management of this complication: including the relief of ductal obstructions, the stenting of leakages and the drainage of bulging or non-bulging fluid collections. Conclusion: Practical problems and issues as well as the need for future improvements in management of the patients having such complications should be considered in larger reviews.