Recurrent GI Bleeding From Colo Pancreatic Fistula - A Rare Entity

Introduction: Acute pancreatitis is an acute inflammatory condition affecting the pancreas. Colonic complications rarely occur with acute and chronic pancreatitis. Localized ileus, obstruction, colonic ischemia, hemorrhage and fistula formation have been reported together with acute pancreatitis. Colo-pancreatic fistula occurs at a rate of 3% to 10% in patients with severe acute pancreatitis. Here, we discuss the case of a patient with recurrent GI bleeding from a colo-pancreatic fistula. Case Description/Methods: A 62-year-old White male with past medical history of COPD, CAD s/p PCI, history of paroxysmal atrial fibrillation on Eliquis, diabetes presented with complaints of bleeding per rectum. He denied any other complaints. MRI abdomen showed pancreatic pseudocyst with possible fistulization of the pancreatic pseudocyst to the proximal descending colon (Fig 1A). Patient underwent EGD and colonoscopy. Colonoscopy showed evidence of pancreatico enteric fistula distal to the splenic flexure, the remnants were cleared on lavage and patient was discharged once stable (Fig 1B). One month later patient presented with another episode of recurrent GI bleeding he required 2 units of PRBC given the prior findings on the colonoscopy, patient was referred to pancreatic surgeon for further intervention of the colo-pancreatic fistula. Discussion: CPF is a rare condition associated with high mortality in patients with acute pancreatitis. Abdominal CT with or without contrast is often used for diagnosis; however, colonoscopy is also used to detect CPF. Given the anatomical proximity of the left part of the colon to the pancreas, CPF is commonly seen on the left side. Patients present with symptoms such as nausea, abdominal pain, vomiting and gastrointestinal bleeding. In contrast to other pancreatic enteric fistulas, CPF is associated with a high risk of severe hemorrhage, perforation or infection. Unlike other pancreatic enteric fistulas CPF do not close spontaneously, surgery is often the recommended treatment; however, less invasive endoscopic interventions, such as those using conventional hemoclips or over the scope clip, have been reported to have successful outcomes.Figure 1.: Fig 1A: MRI Abdomen showing pancreatic pseudocyst (shown by two blue arrows). Fig 1B: Colonoscopy showing fistulous opening in the descending colon distal to splenic flexure (shown by black arrow).