Pancreatico-gastric fistula

Case contributed by Dr Bruno Di Muzio

Presentation

Epigastric pain. Previous history of ETOH abuse and multiple episodes of pancreatitis.

Patient Data

Age: 45 years
Gender: Male
CT

CT Abdomen and pelvis

There is a small hypodense tract between the inferior surface of the proximal stomach and the pancreatic tail, measuring approximately 14 x 15 x 21 mm, within thin enhancing wall, compatible with pancreatico-gastric fistula. There is associated thickening of the wall of the stomach in this region. Otherwise normal appearance of the pancreas.

Generalized hypoattenuation of the liver is suggestive of fatty infiltration.

No intra-abdominal free fluid or free gas. No dilated loops of small or large bowel. Sigmoid colon diverticulae with mild surrounding fat stranding, in keeping with mild/early diverticulitis if clinically correlated. Normal appearance of the appendix.

CT

CT Abdomen and pelvis - 5 days later

Edematous pancreas with diffuse peripancreatic fat stranding, particularly at the pancreatic body and tail, significantly increased compared to previous CT.  Non-enhancement the area of pancreatic tail, just adjacent to the gastric pancreatic fistula. This area of pancreas demonstrated enhancement on the portal venous contrast on the previous CT. 
Intraperitoneal free fluid along the bilateral pericolic gutters and extending into the pelvis, particularly on the right side.
Normal enhancement of the superior mesenteric and portal veins, however there is a 3 cm segment of non-enhanced splenic vein.

Bilateral minor dependent basal atelectasis and compressive consolidation, right greater than left, with trace right pleural effusion.
Hyperattenuation of liver parenchyma is suggestive of fatty infiltration.  Liver is otherwise unremarkable.  The gallbladder, spleen, bilateral adrenals and bilateral kidneys are unremarkable.
Mild prominence of the small and large bowel compared to the previous study.  No features of mechanical obstruction.  Sigmoid colonic diverticula without evidence of acute diverticulitis.  Gaseous distension of the cecum and ascending colon.
No suspicious osseous lesions.

Case Discussion

This case illustrates what appears to represent a pancreatico-gastirc fistula in a patient with the previous history of episodes of pancreatitis. The communication through the gastric mucosa is difficult to be established on imaging and this could be further assessed by gastroscopy (not available for this case discussion). A differential to consider would be an involuting pseudocyst, which was felt less likely. Unfortunately, previous imaging related to the previous pancreatitis episodes were not available for comparison. 

The patient was admitted with a clinical picture of acute pancreatitis and the 5 days apart scans show evolution to severe pancreatitis with pancreatic necrosis. 

PlayAdd to Share

Case information

rID: 59612
Published: 24th Apr 2018
Last edited: 9th Apr 2019
Inclusion in quiz mode: Included

Updating… Please wait.

 Unable to process the form. Check for errors and try again.

 Thank you for updating your details.