Pancreatic fistula
| Pancreatic fistula | |
| MeSH | D010185 |
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Pancreatic fistula Microchapters |
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Diagnosis |
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Pancreatic fistula On the Web |
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American Roentgen Ray Society Images of Pancreatic fistula |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
A pancreatic fistula is an abnormal connection between the epithelialized surfaces of the pancreatic duct and adjacent or distant structures, organs or cavities. Clinical criteria defined by the International Study Group for Pancreatic Fistula (ISGPF) is a measurable drain output containing pancreas-derived enzyme amylase which is greater than three times the upper limit of the normal serum level measured on or after postoperative day three. A revised grading for pancreatic fistula was proposed by ISGPF, according to which pancreatic fistula is graded either into a new category which involve an asymptomatic leakage from the pancreas called biochemical leak (BL), or Grade B including patients who undergo surgical procedures such as percutaneous or endoscopic drainage or angiographic procedures in order to promote the healing of fistula and Grade C including patients with organ failure requiring reoperations and mortality as a result of complication from pancreatic fistula.
Historical Perspective
Classification
Pancreatic fistula can be classified anatomically as;
- Internal fistula: The pancreatic duct communicates with internal organs or body cavity such as pleural or peritoneal cavity.
- External fistula: The pancreatic duct communicates with the skin, otherwise known as pancreaticocutaneous fistula.
Pancreatic fistula can also be classified based on the anatomy of the pancreatic duct and the location of injury as;
- Type 1 pancreatic fistula: Involves injury to the pancreatic parenchyma with leakage from the distal part of the pancreatic duct or the side branches.
- Type 2 pancreatic fistula: Involves injury to and leak from the main pancreatic duct.
- Type 3 pancreatic fistula: Occurs as a result of proximal or distal pancreatectomy.
Pancreatic fistula is classified into two categories on the basis of clinical manifestations, complications and severity by the ISGPF as;
- Biochemical pancreatic fistula: This category includes fistula with no significant clinical symptoms.
- Clinically relevant pancreatic fistula: This category includes fistulas under grade B and C, which shows significant clinical symptoms and require surgical interventions, re-surgeries and can complicate into organ failure and death.
Pathophysiology
The pathophysiology of pancreatic fistula involves the disruption of the pancreatic duct either from an iatrogenic insult, underlying inflammatory process or trauma. The disruption of the pancreatic duct causes gradual loss of the integrity of the tissue resulting in the leakage of the pancreatic fluid which induces inflammation and erosions, thereby leading to the formation of abnormal connections between the duct and the surrounding structures.
Causes
Pancreatic fistula can result from different types of insults such as;
- Iatrogenic: External pancreatic fistula is most commonly iatrogenic in etiology. Trauma to the duct during surgery such as pancreaticoduodenectomy, distal pancreatectomy, during endoscopic intervention, extraction of a biopsy sample, pancreatic resection or as a complication of drainage of pancreatic pseudocyst.
- Non-iatrogenic: Includes pathology of the gland such as acute or chronic pancreatitis or trauma to the abdominal structures or organs leading to fistula formation.
Differentiating Pancreatic fistula from other Diseases
Differential diagnosis of a pancreatic fistula may include evaluation for:
- Chronic liver disease leading to abdominal ascites
- Renal failure
- Heart failure
- Malignancy
- Conditions leading to pleural effusion such as malignancy, trauma and infections
- Pancreatitis
- Retroperitoneal bleeding
- Bowel ischemia
Epidemiology and Demographics
Risk Factors
Natural History, Complications and Prognosis
Diagnosis
History and Symptoms | Physical Examination | Laboratory Findings | Chest X Ray | CT | MRI | ERCP | Ultrasound | Other Imaging Findings | Other Diagnostic Studies
Treatment
Medical Therapy | Surgery | Primary Prevention | Secondary Prevention | Cost-Effectiveness of Therapy | Future or Investigational Therapies