Finesse in the Fray: Navigating Pancreatico-colonic Fistulas with Over-the-Scope Clip Magic—Unveiling the Art of Nonsurgical Mastery in Necrotizing Pancreatitis Challenges

Introduction: Acute pancreatitis is marked by inflammation of the pancreas. While a majority experience the mild form, around 20 to 30% progress to a severe state, posing a substantial challenge in timely identification for effective management. Notably, 20 to 40% of severe cases manifest infection within pancreatic and peripancreatic necrotic regions, exacerbating organ dysfunctions.

Case Description: In our recently reported case, a 37-year-old male patient with a confirmed diagnosis of acute necrotizing pancreatitis accompanied by walled-off necrosis (WON) over the past 4 months presented with new symptoms. The patient complained of pus in stool for the last 10 days, coupled with a high-grade fever with chills persisting for the last 3 days. Hematological analysis revealed an increased total leucocyte count (22,000) with neutrophilic predominance, as well as microcytic anemia (Hb: 8 gm%, mean corpuscular volume: 64). However, amylase, lipase, liver function test, and renal function test fell within normal ranges. Abdominal ultrasonography revealed a distended gallbladder with echogenic foci and an obscured pancreas head due to a gaseous abdomen. A 45 × 36 mm collection with a fistular connection of 8 to 9.5 mm with the descending colon was identified. A contrast-enhanced computed tomography of the abdomen demonstrated gross pancreatic necrosis with marked peripancreatic fat stranding, and a moderate amount of localized/multiseptated peripancreatic fluid collection with interspersed air foci. The fluid extended infero-laterally into the left paracolic gutter and left posterior para-renal space, displacing the descending colon anteriorly, with a focal dehiscence in the posterior wall, indicating colonic fistulization. The defect size approximated 10 mm. A conclusive diagnosis of acute necrotizing pancreatitis with WON and colonic fistula was established, prompting the initiation of antibiotic therapy and intravenous fluids. Subsequently, a comprehensive treatment plan involving percutaneous drainage and endoscopic management was executed. The initial step involved the placement of percutaneous catheter drainage (PCD) with continuous negative pressure irrigation. Following this, a colonoscopy was performed, identifying a fistulous opening located 30 cm from the anal verge, exhibiting necrotic pus-like discharge. The opening was marked with methylene blue, and an over-the-scope clip (OTC) was applied over the fistulous opening. Post-OTC application, the per rectal pus discharge decreased, while percutaneous drainage demonstrated an increase. The patient was diligently followed up in the outpatient department, with a continuous decrease in drainage quantity noted. Eventually, the PCD was successfully removed 20 days after its initial insertion.

Figure 1

Discussion: Gastrointestinal fistulas represent potentially life-threatening complications secondary to acute necrotizing pancreatitis (ANP), with reported incidence rates ranging from 3 to 47% in various studies. Notably, the presence of infected pancreatic necrosis (IPN) has emerged as an independent risk factor for the development of gastrointestinal (GI) fistulas. Among these, colonic fistulas prevail as the most common, occurring in 61% of patients diagnosed with GI fistulas in the context of IPN. While the majority of upper GI fistulas exhibit successful nonsurgical management, the literature suggests that approximately 7 out of 10 patients with colonic fistulas may require surgery. Traditionally, the key approach to managing colonic fistulas involves controlling the source of infection through surgical diversion of the faecal stream, and when necessary, resection of segments of the colon exhibiting full thickness necrosis. However, recent trends in management have seen success with more conservative approaches that integrate percutaneous drainage and endoscopic techniques, potentially averting the need for surgery in a significant proportion of patients with GI fistulas. In this reported case, the patient presented with ANP and a colonic fistula. The employed step-up strategy, incorporating percutaneous drainage and endoscopic interventions, proved effective in managing the colonic fistula, thereby obviating the need for surgery. This case underscores the evolving and promising role of nonsurgical interventions in the management of GI fistulas associated with ANP.

Publication History

Article published online:
22 April 2024