Pancreatic fistula

Pancreatic fistula, also known as pancreatic fistula, is an uncommon pathologic condition in which a communication or channel is formed between the pancreas and neighboring organs or structures. [1], [2] There are three different ways to classify pancreatic fistulas: anatomy, underlying disease process, and immediate predisposing cause. Traditionally, anatomically they are divided into internal and external. [3] Internal pancreatic fistula occurs when the pancreatic duct ruptures, resulting in its communication with the abdominal or pleural cavity. External pancreatic fistula, also known as pancreatic cutaneous fistula, is a communication of the pancreatic duct with the skin, resulting in drainage of pancreatic fluid. In external pancreatic fistula, it can be further defined if it is associated with postoperative causes.

Pancreatic fistulas can result from a variety of pathologic processes, and their presence can be associated with a variety of medical conditions.

The most common cause of pancreatic fistula is pancreatitis, an inflammatory disease of the pancreas. Pancreatitis can cause damage to the pancreatic tissue and the formation of fistulas, through which pancreatic juice or infection can escape into surrounding tissues or organs.

Symptoms of pancreatic fistula may include pain in the upper abdomen, fluid discharge through skin openings or other orifices, and signs of infection or inflammation. Diagnosis of pancreatic fistula may require the use of various examination techniques such as computed tomography (CT), magnetic resonance imaging (MRI), endoscopic cholangiopancreatography (ECPG), and others.

Treatment for pancreatic fistula may include conservative methods, such as antibiotics and pain medications, or surgery to remove the fistula and restore normal pancreatic function. Treatment will depend on the patient's specific condition and the nature of the fistula.

Causes of the pancreatic fistula

Pancreatic fistula can be caused by a variety of causes and conditions. [4] Here are some of the possible causes:

1. Pancreatitis: Inflammation of the pancreas (pancreatitis) can lead to fistula formation. Pancreatitis can be acute (sudden) or chronic (permanent), and in both cases, the condition can damage the tissue of the gland and surrounding organs, which can lead to fistula formation.
2. Pancreatic cysts: Cysts that form in thepancreas can cause fistulas when they rupture into neighboring organs or the intestines.
3. Trauma or surgery: Abdominaltrauma or surgical procedures on the pancreas can also be a cause of fistula formation.
4. Inflammatory diseases: Some inflammatory diseases, such as Crohn's disease or ulcerative colitis, can cause inflammation in the pancreatic area and result in fistula formation.
5. Malignant tumors: Cancer of the pancreas or surrounding tissues can also cause fistulas, as the tumor can destroy tissue and infiltrate nearby organs.
6. Infections: Infections of the pancreas can lead to fistula formation.
7. Other Causes: In rare cases, fistula can be caused by other factors such as uncontrolled alcohol consumption or medical procedures.

Symptoms of the pancreatic fistula

Symptoms of pancreatic fistulas can vary depending on their location and degree of complication. Clinical features of patients range from asymptomatic to exhibiting signs and symptoms. [5], [6] The following are some possible symptoms that may accompany pancreatic fistulas:

1. Upper abdominal pain: Pain can occur due to inflammation and tissue destruction caused by a fistula.
2. Breath odor: In some cases, a pancreatic fistula can lead to impaired digestion and the formation of hydrogen with gray algae, which can cause an unusual breath odor.
3. Diarrhea: Fistulas can cause disruption of the normal digestive process and hence diarrhea.
4. Release of pancreatic juice: Fistulas can lead to the release of pancreatic juice into other organs or body cavities, which can cause irritation and inflammation.
5. Jaundice: If a pancreatic fistula disrupts the normal flow of bile, it can cause jaundice, which is characterized by yellow staining of the skin and the sclera of the eyes.
6. Hepatitis: Fistulas can also lead to inflammation of the liver (hepatitis).
7. Weight loss and general weakness: These symptoms can occur due to disruption of normal digestion and absorption of nutrients.

Diagnostics of the pancreatic fistula

Diagnosis of pancreatic fistula may include the following methods:

1. Clinical Assessment: The physician performs a physical examination and collects a history to identify symptoms that may suggest fistula, such as upper abdominal pain, jaundice, or digestive disturbances.
2. Laboratory tests: Blood tests such as amylase and lipase levels may be performed to assess pancreatic function and detect the presence of inflammation.
3. Instrumental methods:
   • Ultrasound (ultrasonography): Ultrasound of the pancreas can help detect the presence of fistulas and evaluate their characteristics.
   • Computed tomography (CT) scan: CT scans can be performed to visualize the pancreas and surrounding tissues in more detail.
   • Magnetic resonance imaging (MRI): MRI may be used to evaluate the pancreas and related structures in more detail. [7]
   • Endoscopic cholangiopancreatography (ECPPG): This is an invasive procedure in which a contrast agent is injected through an endoscope to visualize thepancreas and biliary tract. [8]
4. Surgical methods: If fistulas are suspected, surgical intervention such as surgery may be required to remove the fistula and restore normal anatomy.

Differential diagnosis

The differential diagnosis of pancreatic fistula is broad and depends on the patient's condition depending on the location and size of the fistula. The differential diagnosis will include causes of abdominal pain, ascites, and pleural effusion. Causes of abdominal pain include trauma, retroperitoneal hemorrhage, intra-abdominal malignancy, pancreatitis, choledocholithiasis, mesenteric ischemia, bowel obstruction, organ rupture, and peritonitis. [9]

Treatment of the pancreatic fistula

Treatment of pancreatic fistula depends on its type, location, and clinical symptoms. [10] The most common treatments for pancreatic fistula include the following methods and steps:

1. Diagnosis: Diagnosis must first be performed to accurately determine the presence of fistulae and their characteristics. For this purpose, various examination methods such as computed tomography (CT), magnetic resonance imaging (MRI), endoscopic cholangiopancreatography (ECPG), ultrasound and others can be used.
2. Conservative treatment: If pancreatic fistulas are not causing significant symptoms or complications, your doctor may suggest conservative treatment, which includes taking antibiotics to fight infection and pain medications to reduce pain.
3. Drainage: In some cases, fistulas may be drained to facilitate the outflow of fluid or pus. This can be done using special stents or drainage systems inserted through endoscopic access. [11], [12]
4. Surgery: If pancreatic fistulas cause serious complications or cannot be treated conservatively, surgery may be necessary. During surgery, the surgeon may remove part of the pancreas, cut the fistula, or perform other procedures to restore normal anatomy.
5. Follow-up: After treatment, regular medical follow-up is necessary to monitor the pancreas and to rule out recurrence of fistula.

Forecast

The prognosis for pancreatic fistula depends on several factors, including the cause of the fistula, its location, the extent of damage to surrounding tissues, and the timeliness of treatment. The overall prognosis can range from favorable to serious and even fatal. The following are general points to consider:

1. Cause and nature of fistula: The prognosis will depend on the underlying disease or condition that caused the fistula. For example, fistulas caused by pancreatitis or infection may be manageable and have a better prognosis than fistulas caused by pancreatic cancer.
2. Fistula location: The locationof fistulas can greatly affect prognosis. Fistulas that are closer to the body surface or in accessible areas for surgery may be more easily treated.
3. Extent of damage: If the fistula has caused significant damage to surrounding tissues or organs, the prognosis may be less favorable. The damage may have affected the function of the pancreas or other organs.
4. Timeliness of treatment: It is important to start treatment of fistula as early as possible. Delay in diagnosis and treatment can increase the risk of complications and worsen the prognosis.
5. Individual patient characteristics: Prognosis may also depend on the patient's general health, age, and the presence of other medical problems.

In cases of pancreatic fistula, early medical attention, proper diagnosis, and adequate treatment can improve prognosis and help prevent complications.

List of authoritative studies related to the study of pancreatic fistulas

1. "Pancreatic Fistulas: Current Evidence and Strategy - A Narrative Review"

   • Authors: Clara Meierhofer, Reinhold Fuegger, Matthias Biebl, Rainer Schoefl
   • Publication Year : 2023

2. "The measurement of amylase in drain fluid for the detection of pancreatic fistula after gastric cancer surgery: an interim analysis"

   • Authors: De Sol A, Cirocchi R, Di Patrizi MS, Boccolini A, Barillaro I, Cacurri A, Grassi V, Corsi A, Renzi C, Giuliani D, Coccetta M, Avenia N
   • Publication Year : 2015

3. "Diagnosis of postoperative pancreatic fistula."

   • Authors: Facy O, Chalumeau C, Poussier M, Binquet C, Rat P, Ortega-Deballon P
   • Publication Year : 2012

4. "Drain amylase value as an early predictor of pancreatic fistula after cephalic duodenopancreatectomy"

   • Authors: Dugalic VD, Knezevic DM, Obradovic VN, Gojnic-Dugalic MG, Matic SV, Pavlovic-Markovic AR, Dugalic PD, Knezevic SM
   • Publication Year : 2014

5. "Endoscopic management of pancreaticopleural fistulas: a report of three patients"

   • Authors: Koshitani T, Uehara Y, Yasu T, Yamashita Y, Kirishima T, Yoshinami N, Takaaki J, Shintani H, Kashima K, Ogasawara H, Katsuma Y, Okanoue T
   • Publication Year : 2006

6. "Pancreatic Leaks and Fistulae: An Endoscopy-Oriented Classification."

   • Authors: Mutignani M, Dokas S, Tringali A, Forti E, Pugliese F, Cintolo M, Manta R, Dioscoridi L
   • Publication Year : 2017

7. "Pancreatic pseudocysts, ascites, and fistulas."

   • Author: Yeo CJ
   • Publication Year : 1994

8. "A Single-Center Experience of Internal Pancreatic Fistulas."

   • Authors: Siva Sankar A, O K P, Banu KJ, Pon Chidambaram M
   • Publication Year : 2022

9. "Redo pancreaticojejunal anastomosis for late-onset complete pancreaticocutaneous fistula after pancreaticojejunostomy"

   • Authors: Yamamoto M, Zaima M, Yazawa T, Yamamoto H, Harada H, Yamada M, Tani M
   • Publication Year : Not specified

10. "Pancreatic Fistula"

• Author: Various authors contribute to this source, covering various aspects of pancreatic fistulas.
• Publication Year : Ongoing updates

Literature

Saveliev, V. S. Clinical Surgery. In 3 vol. Vol. 1 : national manual / Ed. By V. S. Saveliev. С. Savelyev, A. I. Kirienko. - Moscow : GEOTAR-Media, 2008.