Korean J Gastroenterol.  2019 Jun;73(6):365-369. 10.4166/kjg.2019.73.6.365.

Feasibility of Adopting the “Step-up Approach” in Managing Necrotizing Pancreatitis-induced Pancreatic-colonic Fistula

• Yim SK
• Kim SH
• Seo SY
• Yang HC
• Lee SO

• KMID: 2454099
• DOI: http://doi.org/10.4166/kjg.2019.73.6.365

Abstract

Managing acute pancreatitis is clinically challenging because of the generally poor patient condition, the variety of treatment options depending on the severity and complications, and the uncertainty of outcomes. Recently, the step-up approach, which involves less invasive initial treatment and more invasive subsequent treatment, where necessary, has been proposed as the mainstay of managing pancreatitis. This paper presents a case of a 57-year-old man with severe acute pancreatitis, who developed an unexpected fistula in the rectum, which was treated successfully using the step-up approach. In managing this case, the authors faced clinical challenges in determining the infection of necrotic tissue in the early phase of the disease, the optimal timing and method of drainage, and the fistula closure or repair technique. Successful management of this case using the step-up approach validated current recommendations and suggests that it is a reasonable treatment strategy for pancreatic-colonic fistulas. This case also highlights the importance of an awareness that pancreatitis-associated complications can develop in an unexpected manner.

Keyword

Pancreatitis, acute necrotizing; Colon; Rectum; Fistula

MeSH Terms

Colon
Drainage
Fistula*
Humans
Methods
Middle Aged
Pancreatitis
Pancreatitis, Acute Necrotizing
Rectum
Uncertainty

Figure

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  Fig. 1 Computed tomography (CT) scans of the patient. Initial CT scan reveals edematous change of the pancreatic head with acute peripancreatic fluid collection (A) extending to the pelvic cavity (B). Follow-up scan at day 20 shows a massive increase in necrotic collection and wall formation at the same level (C).

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  Fig. 2 Sigmoidoscopy image of the fistula opening. Sigmoidoscopy at day 25 reveals a fistula opening in the rectum (A) with pus discharge (B).

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  Fig. 3 Radiologic confirmation of the fistula tract. Contrast media filled rectum and sigmoid colon after contrast media injection to the percutaneous drainage tube (A) and computed tomography scan showing the fistula tract (B, white arrow).

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