Pancreatic Fistulas, etiology, pathogenesis, clinical picture, diagnosis and treatment

1. Pancreatic Fistulas
By Nirmal Jose Mathew
Group 25
6th Course, 11th Semester
by MedCredible

2. Definition
Abnormal Connection
An Abnormal connection between the pancreas (Pancreatic duct epithelium) and adjacent
or distant organs, structures or spaces thus allowing leakage of enzyme - rich pancreatic
fluid.

3. Etiology
1. Pancreato duodenectomy (eg:- Whipple's Procedure)
2. Distal pancretoduodenostomy.
3. Pancreatic trauma
4. Necrotizing pancreatitis surgeries
5. Chronic pancreatitis surgeries.
6. Pancreatic pseudocyst/Abscess drainage.

4. Pathogenesis
1
Pancreatic Injury
Initial pancreatic injury or surgical
trauma leads to disruption of the
pancreatic duct or tissue. 2 Duct Damage
Damage to the pancreatic duct
integrity causes leakage of
pancreatic secretions.
3
Inflammation
Inflammation and release of pro-
inflammatory mediators further
weaken tissue and surrounding
structures.
4 Enzyme Leakage
Leakage of pancreatic enzymes
erodes neighboring tissues, creating
an abnormal connection (fistula).
5
Persistent Leakage
Prolonged leakage may lead to
infection, abscess formation, and
impaired healing. 6 Contributing Factors
Factors like poor wound healing,
sphincter dysfunction, and infection
contribute to fistula persistence.
7
Clinical Manifestations
Clinical manifestations include
abdominal pain, fever, drainage from
surgical sites, and changes in drain
output.

5. Classification
Internal Fistula
An abnormal
connection
between the
pancreas and
adjacent or distant
organs or
structures, allowing
leakage of enzyme-
rich pancreatic fluid.
External Fistula
An abnormal
connection
between the
pancreas and the
skin, allowing
pancreatic
secretions to drain
externally.
Low Output
Fistula
A fistula that
produces less than
200 ml of
pancreatic fluid per
day.
High Output
Fistula
A fistula that
produces more
than 200 ml of
pancreatic fluid per
day.

6. Clinical Picture
Abdominal Pain
Abdominal pain, often severe and localized.
Fever
Fever indicating inflammation or infection.
Fluid Accumulation
Abdominal distension due to fluid
accumulation.
Drainage
Drainage of pancreatic fluid from wounds
or drains, with changes in output color or
consistency.

7. Diagnosis
Laboratory Investigation - CBC - Anemia, Leukocytosis shift to left,
Increased ESR - Biochemical Blood Analysis
- Increased CRP, Serum Amylase (>1000
IU/L),Serum Lipase, Serum Protein (>3g/dl) -
Output Drainage of Fluid after Post operative
Day 3 analysis (3x Amylase), Pleural / Ascites
fluid level >1000 IU/L
Instrumental Investigation - CT scan/ MRI - ERCP - Contrast Enhanced
Fistulography - Endoscopic UltraSound

8. Treatment
1. Conservative
Management:
NPO (Nothing by Mouth): Fasting allows the
pancreas to rest and reduces pancreatic
secretions, aiding in fistula closure.
Pain Management: Relief of pain with
analgesics to improve patient comfort.
Nutritional Support: IV fluids, total parenteral
nutrition (TPN), or enteral nutrition to maintain
adequate nutrition and promote healing.
Antibiotics: Used to prevent or treat infections,
especially in the case of infected pancreatic
necrosis.

9. Endoscopic Interventions
Endoscopic Stenting
Placing stents in the pancreatic duct or bile duct
to redirect the flow and allow the fistula to heal.
Endoscopic Sphincterotomy
Cutting the sphincter of Oddi to facilitate
drainage and reduce pressure on the pancreatic
duct.

10. 3. Surgical Interventions
1
Pancreatic Resection
Partial or total removal of the pancreas may be required in severe cases.
2
Pancreaticojejunostomy
Surgical creation of a new connection between the pancreas and the
small intestine to bypass the fistula.
3
Distal Pancreatectomy
Removal of the tail of the pancreas where the fistula is located.
4
External Drainage
External drainage of pancreatic secretions to
allow the fistula to heal.