Successful Conservative Management of Pancreatitis complicated by Pancreatogastric Fistula

Objective: To identify pancreatogastric fistula as a rare complication of organized pancreatic necrosis. Case Report: 48 year old male with a history of alcohol abuse presented with severe epigastric pain for 5 days and hematemesis and melena for about 24 hours prior to presentation. On admission, he was hypotensive (96/62mmHg), tachycardic (107beats/min) with epigastric tenderness and maroon stool in rectal vault. His hemoglobin was 7.7 g/dl, WBC count was 22.1 K/mm3 and lipase was 16 U/L. CT scan showed chronic pancreatitis and organized pancreatic necrosis abating the stomach. EGD showed clotted blood in the entire stomach but no site of active bleeding was identified. A large fistula leading to pseudocyst was found in the cardia. This was draining pus and debris. The cyst was accessed by the gastroscope for possible irrigation and debridement. However, bleeding of arterial nature appeared from within the cyst that could not be stopped despite epinephrine injections. Surgical intervention was initially planned but a tagged RBC scans done soon after endoscopy suggested against ongoing bleeding. In the absence of active bleed and ongoing necrotizing and inflammatory process emergent surgical intervention was deferred and he was monitored in the ICU. His hemoglobin remained stable requiring no further transfusions. Patient was pain free and tolerating regular diet after 3 days of hospitalization. Repeat CT scan showed reduction in cyst size to less than half within a week of initial. Conclusion: Organized pancreatic necrosis in the setting of chronic relapsing pancreatitis can drain into adjacent organs through a fistula. This can help in the healing process and can potentially save a patient from challenging and difficult surgical intervention.