This document defines pancreatic fistula and describes its types, pathogenesis, clinical presentation, diagnosis, treatment and prevention. It defines a pancreatic fistula as an abnormal connection between the pancreas and other organs due to leakage of pancreatic secretions from damaged pancreatic ducts. It describes external fistulas which communicate with the skin, and internal fistulas which communicate with internal organs. Risk factors include pancreatitis, pancreatic surgery or trauma. Treatment involves reducing pancreatic secretions, intravenous nutrition, possible surgery and somatostatin analogs. Diagnosis involves detecting high amylase levels in drained fluid and imaging tests like CT, MRCP or ERCP can identify locations of fluid collections.

1. Pancreatic Fistula
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STATE BUDGETARY EDUCATIONAL ESTABLISHMENT
OF HIGHER PROFESSIONAL EDUCATIONAL
MINISTRY OF PUBLIC HEALTH OF RUSSIAN FEDERATION
KURSK STATE MEDICAL UNIVERSITY
DEPARTMENT OF SURGERY
Head of Department: MD Phd Prof Ivanov. S. V
KURSK - 2017

2. Definition
A pancreatic fistula is an abnormal
communication between the pancreas and
other organs due to leakage of pancreatic
secretions from damaged pancreatic ducts.

3. Types of Pancreatic Fistulas
 External: An external pancreatic fistula is an abnormal
communication between the pancreas (actually pancreatic
duct) and the exterior of the body via the abdominal wall. Is
one that communicates with the skin, and is also known as a
pancreaticocutaneous fistula.
 Internal: Communicates with other internal organs or spaces.
Can result in pancreatic ascites, mediastinital pseudocysts,
enzymatic mediastinitis, or pancreatic pleural effusions,
depending on the flow of pancreatic secretions from a
disrupted pancreatic duct or leakage from a pseudocyst.

4. Pathogenesis and Etiology
 Both internal and external PFs result from leakage of
pancreatic juice from a disrupted pancreatic duct. This can
occur following acute or chronic pancreatitis, partial
pancreatectomy, or trauma to the pancreatic duct during
upper abdominal surgery, pancreatic biopsy, or blunt
abdominal trauma.
 If the fluid collections (and leak) persist, a fibroinflammatory
rind is formed around the collection, also called a pseudocyst.
 Persistent leakage of pancreatic juice may lead to
spontaneous erosion into a neighboring hollow viscus

5. Chronic alcohol-induced pancreatitis is the most
common pancreatic disease associated with internal
PFs. By contrast, pancreaticocutaneous (external)
fistulas are usually iatrogenic, occurring after
pancreatic resection or percutaneous drainage of
pancreatic pseudocyst, pancreatic abscess, or
organized necrosis. Pancreaticoenteric fistulas can
also be a complication of percutaneously placed
drain catheters into peripancreatic collections
resulting from erosion of the catheter tip into the
bowel.

6. Clinical Picture
 The clinical manifestations of PFs depend upon their size, location,
and the affected organs.
 Internal fistulas — Patients with acute pancreatitis who have internal PFs often
have fistulization into the bowel. As a result, they may be quite ill with fever and
features of sepsis suggesting infected fluid collections. Communications with the
colon, duodenum, biliary tree, and rarely portal vein may result from extensive
necrosis producing symptoms related to the organs involved.
 External fistulas — External fistulas are associated with drainage of fluid from a
defect in the skin and may lead to skin excoriation. They may be classified as high
output fistulas (output exceeding 200 mL/day) or low output (output less than 200
mL/day)

7. Diagnosis
 The diagnosis of PF is often suspected by the clinical setting and radiologic
findings and confirmed by the finding of high levels of amylase in the
extravasated fluid.
 Physical examination — Physical examination findings in patients with pancreatic
ascites may include abdominal distension and flank dullness. A large pseudocyst
may be palpable in the epigastric region. Patients with a thoracopancreatic fistula
may have findings suggesting a pleural effusion including dullness to percussion
over the thorax and diminished breath sounds. Pleural effusions can be unilateral
or bilateral.
 Laboratory tests — The presence of amylase rich fluid is the hallmark of PFs.
Diagnostic and therapeutic paracentesis and/or thoracentesis should be performed
when a pancreas leak is suspected in the setting of ascites or pleural effusions,
respectively. Effluent from external fistulas should be collected for fluid analysis.
 An elevated amylase level, usually > 1,000 IU/L, with protein levels over 3.0 g/dL is
diagnostic.

8. Imaging Test
 Computerized tomography (CT), fistulography, magnetic resonance
cholangiopancreatography (MRCP), and endoscopic retrograde
cholangiopancreatography (ERCP) are the main imaging modalities for the
diagnosis and management of PFs. CT imaging can demonstrate free and
walled off fluid collections in the abdominal and thoracic cavities.
 Endoscopic retrograde cholangiopancreatography - is considered the
diagnostic tool of choice in demonstrating PFs. Has the capability to demonstrate
contrast filling the pancreatic ducts and extravasation in real time.
 Magnetic resonance cholangiopancreatography — Magnetic resonance
cholangiopancreatography (MRCP) may be the initial diagnostic tool for suspected
pancreatic duct injury because of its noninvasive nature, unless therapy is planned
with ERCP.

9. Treatment
 The over secretion of the pancreatic enzymes is brought down by reducing the
amount of food intake.
 The nutrition of the patient is maintained by intravenous feeding where the normal
procedures of eating and digestion can be avoided.
 Fistulectomy or removal of the fistula along with the associated part of the
pancreas is also essential in some cases.
 Method of pancreatic reconstruction - Kausch-Whipple Method —
Pancreaticojejunostomy and gastrojejunostomy are well established methods of
reconstruction after pancreatic head resection. There are two predominant
methods of reconstruction: end-to-side duct-to-mucosa anastomosis or
invagination of the pancreatic remnant.

11. Prevention
 Somatostatin and its analogues — The role of somatostatin
and its analogues in the prevention of PFs remains unclear.
Benefit in reducing morbidity following pancreatic operations.
Significant reduction in the likelihood of fistula formation,
when fistulas were defined as an amylase rich effluent.
 Prophylactic pancreatic stenting — Placement of a
pancreatic stent has the potential to decompress the main
pancreatic duct and provide drainage of pancreatic
secretions.

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