Ambreen A. Merchant, MBBS1, Jason Brown, MD2, Emad Qayed, MD, MPH2 1Emory University, Decatur, GA; 2Emory University, Atlanta, GA
Introduction: Pancreatico-pericardial fistula is a rare complication of chronic pancreatitis. The diagnosis requires a high index of suspicion, and a multidisciplinary approach should be adopted in managing these patients.
Case Description/Methods: 34-year-old male with HIV (not on antiretrovirals, CD4 count 114 cells/mm3) and chronic alcoholic pancreatitis presented to the emergency room with 2 months of midsternal, sharp chest pain and 1 week of epigastric pain. He was febrile, had signs of sepsis, and was started on vancomycin and ceftriaxone. He developed early signs of cardiac tamponade, and pericardiocentesis yielded 800mLs of bloody-appearing fluid with 1828 nucleated cells /uL (72% neutrophils), LDH 1456 unit/L, glucose 68 mg/dl, protein 4.7 g/dl, and lipase 52217 unit/L. The patient was stabilized and discharged on colchicine and ibuprofen. Two weeks later, he was readmitted with worsening chest pain and hypotension. Transthoracic echocardiography showed a dilated inferior vena cava, flattened septum, and compression of right atrium by a pericardial cyst. A CT abdomen showed a peripancreatic fluid collection measuring 4.9x4.2x8 cm, extending from the proximal pancreatic body through the diaphragmatic hiatus into the pericardial space, with a mass effect on the right atrium. The patient was diagnosed with pancreatico-pericardial fistula. ERCP revealed a pancreatic duct leak in the proximal body. A 10F 9 cm pancreatic duct stent was placed in the main pancreatic duct across the leak site. The patients received octreotide and total parenteral nutrition. He also underwent percutaneous drain placement into the peripancreatic fluid collection. Repeat transthoracic echocardiography showed no effusion with a normal right atrium and inferior vena cava. The patient’s condition improved, the drain was removed, and he was discharged on a regular PO diet. Outpatient ERCP two months later showed resolution of the pancreatic duct leak and the pancreatic stent was removed.
Discussion: The diagnosis of pancreatico-pericardial should be suspected in patients with chronic pancreatitis and pericardial effusions. The clinical features of this condition are variable and require thorough, multidisciplinary work-up. A high pericardial fluid lipase and abdominal/thoracic imaging establish the diagnosis. ERCP serves as both a diagnostic and a therapeutic modality. Similar to other pancreatic fistulas, stent placement to treat the pancreatic duct leak is the treatment of choice.
Ambreen Merchant indicated no relevant financial relationships.
Jason Brown indicated no relevant financial relationships.
Emad Qayed indicated no relevant financial relationships.
Ambreen A. Merchant, MBBS1, Jason Brown, MD2, Emad Qayed, MD, MPH2. P0043 - Pancreatico-Pericardial Fistula as a Complication of Chronic Pancreatitis - A Rare Case Report, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.