Spontaneous Fistulization of WON into Colon with Multiple Communications with Hemorrhage

Background: Waled-off necrosis is a well-known complication of severe acute necrotizing pancreatitis. Gastrointestinal fistulas are uncommon complication of acute or chronic pancreatitis. Fistula usually occur at the splenic flexure of colon and rarely at other parts of GIT including duodenum. Spontaneous rupture occurs in 5% of cases, with half of them rupturing into hollow viscus and half of them into peritoneum. Colonic fistulae usually require surgical treatment and rarely may heal with supportive management alone

Case Description: A 34-year-old gentle man, known ethanol consumer with no comorbidities, got diagnosed with severe acute necrotizing pancreatitis with Pseudocyst 2 months back and he was managed medically and he was taking liquid diet for last 1 to 1 and half months. He presented to us with complaints of loose stools for 3 days 4 to 5 episodes per day, black colored associated with hematochezia. Not associated with pain abdomen, abdominal swelling, loss of consciousness, SOB, vomiting, fever. No past surgical history. He is conscious, coherent, hypotensive, pale. On blood investigations he was found to be having hemoglobin of 1.5 g/dL. He was started on IVF bolus, inotropes, IV antibiotics, IV PPI, and other supportive measures. CT abdominal angio showed mild heterogenous attenuation and enhancement of pancreas. A large irregular peripherally enhancing collection in gastrosplenic region extending along the left anterior renal fascia and retromesenteric plane up to left iliac fossa and showing suspicious communication with the descending colon through a defect along its posteromedial wall and extending along the mesentery to the right iliac fossa up to the medial paracecal location and multiple air foci in the collection. UGI Endoscopy was normal . Colonoscopy revealed Multiple fistulous openings with connection to retroperitoneum. ([Fig. 1]) Patient Hb is holding at 6.9 gm%, inotropes weaning done and advised for diversion ileostomy with necrosectomy under high risk. But patient relatives counselled about same and planned for conservative management with TPN support and was on follow-up.

Fig. 1 Colonoscopic view: colonic fistula communicating with retroperitoneum.

Fig. 2 CT angiography: collection in gastrosplenic region with gas.

Publication History

Article published online:
22 April 2024