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| {{SI}} | | {{Pancreatic_fistula}} |
| {{CMG}} | | {{CMG}} |
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| ==Overview== | | ==[[Pancreatic fistula overview|Overview]]== |
| A '''pancreatic fistula''' is an abnormal communication between the [[pancreas]] and other organs due to leakage of pancreatic secretions from damaged pancreatic ducts. An ''external'' pancreatic fistula is one that communicates with the skin, and is also known as a pancreaticocutaneous fistula, whereas an internal pancreatic fistula communicates with other internal organs or spaces. Pancreatic fistulas can be caused by pancreatic disease, trauma, or surgery.
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| ==Historical Perspective== | | ==[[Pancreatic fistula historical perspective|Historical Perspective]]== |
| Internal pancreatic fistulas were first described by Smith (1953), and elaborated upon by Cameron et al (1976).
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| ==Classification== | | ==[[Pancreatic fistula classification|Classification]]== |
| ===External Pancreatic Fistulas===
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| An '''external pancreatic fistula''' is an abnormal communication between the [[pancreas]] (actually [[pancreatic duct]]) and the exterior of the body via the abdominal wall.
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| Loss of [[bicarbonate]]-rich pancreatic fluid via a pancreatic [[fistula]] can result in a hyperchloraemic or normal [[anion gap]] [[metabolic acidosis]]. Loss of a small volume of fluid will not cause a problem but an acidosis is common if the volume of pancreatic fluid lost from the body is large.
| | ==[[Pancreatic fistula pathophysiology|Pathophysiology]]== |
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| ===Internal Pancreatic Fistulas=== | | ==[[Pancreatic fistula causes|Causes]]== |
| '''Internal pancreatic fistulas''' can result in pancreatic ascites, mediastinital pseudocysts, enzymatic mediastinitis, or pancreatic pleural effusions, depending on the flow of pancreatic secretions from a disrupted pancreatic duct or leakage from a pseudocyst (Cameron et al, 1976).
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| ==Pathophysiology== | | ==[[Pancreatic fistula differential diagnosis|Differentiating Pancreatic fistula from other Diseases]]== |
| Internal pancreatic fistuals are most commonly cause by disruption of the pancreatic duct due to [[chronic pancreatitis]]. The chronic pancreatitis is usually alcoholic in origin in adults, and traumatic in origin in children. They may also be caused by leakage from a pancreatic pseudocyst.
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| Anterior disruption of a pseudocyst or a pancreatic duct leads to leakage of pancreatic secretions into the free peritoneal cavity, leading to '''pancreatic ascites'''. If the duct is disrupted posteriorly, the secretions leak through the retroperitoneum into the mediastinum via the aortic or esophageal hiatus. Once in the mediastinum, the secretions can either be contained in a '''mediastinal pseudocyst''', lead to '''enzymatic mediastinitis''', or, more commonly, leak through the [[pleura]] to enter the chest and form a chronic '''pancreatic [[pleural effusion]]'''.
| | ==[[Pancreatic fistula epidemiology and demographics|Epidemiology and Demographics]]== |
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| | ==[[Pancreatic fistula risk factors|Risk Factors]]== |
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| | ==[[Pancreatic fistula natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
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| ==Diagnosis== | | ==Diagnosis== |
| ===Symptoms===
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| * Marked recent weight loss is a major clinical manifestation
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| * Unresponsiveness of the ascites to diuretics is an additional diagnostic clue.
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| ===Laboratory Findings=== | | ===History and clinical presentation:=== |
| * Pleural or ascitic fluid should be sent for analysis.
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| ** An elevated amylase level, usually > 1,000 IU/L, with protein levels over 3.0 g/dL is diagnostic.
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| * Serum amylase is often elevated as well, due to enzyme diffusion across the peritoneal or pleural surface (Cameron et al, 1976; Lipsett and Cameron, 1992).
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| ===Imaging=== | | ===Imaging:=== |
| ====CT====
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| Contrast-enhanced [[computed tomography]] is used in the diagnosis of pancreatic fistula.
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| ====ERCP==== | | ===Laboratory tests:=== |
| [[Endoscopic retrograde cholangiopancreatography]] (ERCP) may also assist in diagnosis, and is an essential component of treatment.
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| ==Treatment== | | ==Treatment== |
| ===Medical Therapy===
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| The production of pancreatic enzymes is suppressed by restricting the patient's oral intake of food patient in conjunction with the use of long-acting [[somatostatin]] analogues. The patient's nutrition is maintained by [[total parenteral nutrition]].
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| This treatment is continued for 2-3 weeks, and the patient is observed for improvement.
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| ===Surgery===
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| If no improvement is seen, the patient may be receive endoscopic or surgical treatment. If surgical treatment is followed, an ERCP is needed to identify the site of the leak.
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| ==References==
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| {{Reflist|2}}
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| * {{cite book | author = Brooks JR | year = 1983 | title = Surgery of the Pancreas | chapter = Pancreatic ascites | editor = Brooks JR | edition = 1st edition | pages = 230-232 | publisher = WB Saunders | location = Philadelphia}} ISBN 0-7216-2082-5
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| * {{cite journal | author=Cameron JL, Kieffer RS, Anderson WJ, Zuidema GD | title=Internal pancreatic fistulas: pancreatic ascites and pleural effusions | journal=Ann Surg | year=1976 | pages=587-93 | volume=184 | issue=5 | id=PMID 984927}}
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| * {{cite journal | author=Dugernier T, Laterre PF, Reynaert MS | title=Ascites fluid in severe acute pancreatitis: from pathophysiology to therapy | journal=Acta Gastroenterol Belg | year=2000 | pages=264-8 | volume=63 | issue=3 | id=PMID 11189983}}
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| * {{cite journal | author=Iacono C, Procacci C, Frigo F, Andreis IA, Cesaro G, Caia S, Bassi C, Pederzoli P, Serio G, Dagradi A | title=Thoracic complications of pancreatitis | journal=Pancreas | year=1989 | pages=228-36 | volume=4 | issue=2 | id=PMID 2755944}}
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| * {{cite journal | author=Kaman L, Behera A, Singh R, Katariya RN | title=Internal pancreatic fistulas with pancreatic ascites and pancreatic pleural effusions: recognition and management | journal=ANZ J Surg | year=2001 | pages=221-5 | volume=71 | issue=4 | id=PMID 11355730}}
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| * {{cite journal | author=Lipsett PA, Cameron JL | title=Internal pancreatic fistula | journal=Am J Surg | year=1992 | pages=216-20 | volume=163 | issue=2 | id=PMID 1739176}}
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| * {{cite journal | author=Smith EB | title=Hemorrhagic ascites and hemothorax associated with benign pancreatic disease | journal=AMA Arch Surg | year=1953 | pages=52-6 | volume=67 | issue=1 | id=PMID 13064942}}
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| * {{cite journal | author=Takeo C, Myojo S | title=Marked effect of octreotide acetate in a case of pancreatic pleural effusion | journal=Curr Med Res Opin | year=2000 | pages=171-7 | volume=16 | issue=3 | id=PMID 11191006}}
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| [[Category:Gastroenterology]] | | [[Category:Gastroenterology]] |
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| {{WikiDoc Help Menu}} | | ==References== |
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| | [[category:Gastroenterology]] |