Acute pancreatitis complicated by pancreatic pseudocyst and antral fistula in a fragile patient: is conservative management still the first option in the era of interventional endoscopy?

Introduction. A pseudocyst-related antral fistula is a rare but serious consequence of acute pancreatitis, especially in individuals with severe comorbidities.

Case report. This case report describes a 71-year-old male patient with a history of severe comorbidities such as cardiac failure, atrial fibrillation and chronic respiratory insufficiency, presented in the Gastroenterology Department with abdominal pain and nausea. Serum lipase level was elevated so a computed tomography (CT) imaging was performed and an acute pancreatitis was confirmed with a score severity index 6/10. Also, a possible fistulous orrifice between a pancreatic pseudocyst and the stomach antrum was seen. We performed an upper digestive endoscopy that showed a 3 mm fistulous orifice in the gastric antrum. The case was discussed in a multidisciplinary team along with our endoscopic interventionist and Surgical Department. A conservative approach was proposed. The treatment plan included early enteral nutrition, cautious hydration due to his severe comorbidities and proton pump inhibitor medication to reduce gastric acid output. The control CT imaging revealed that the pseudocyst gradually diminished and the fistula closed over 4 weeks. The patient had total relief from symptoms [1] [2].

Conclusion. The above scenario highlights the role of CT imaging and the possibility of conservative management of pancreatic pseudocyst-related fistulas in properly selected patients. Early detection and tailored management may reduce the need for surgical interventions or interventional endoscopy therapy leading the favorable outcomes.

Publication History

Article published online:
27 March 2025

• References

• 1 Guzmán-Calderón E., Chacaltana A., Díaz R., Li B., Martinez-Moreno B., Aparicio J.R.. Head-to-head comparison between endoscopic ultrasound guided lumen apposing metal stent and plastic stents for the treatment of pancreatic fluid collections: A systematic review and meta-analysis. J. Hepato-Biliary-Pancreatic Sci 2022; 29: 198-211
• 2 Lattanzi B., Febbraro I., Pironti E., Bianchi M.. Successful Treatment of Pancreatic Pseudocysto-Duodenum Fistula with Ultrasound Endoscopic Drainage: A Case Report. Int. J. Transl. Med. 2022; 2: 537-542