SAN ANTONIO — Necrotizing pancreatitis (NP) can lead to the involvement of several surrounding structures including the colon and the pleural space. Subsequent development of fistulas, strictures, and infections can significantly contribute to the morbidity and mortality of patients with NP, according to study results presented at the American College of Gastroenterology (ACG) 2019 Annual Scientific Meeting, held October 25-30 in San Antonio, Texas.

Between 2010 and 2019, the investigators identified a total of 515 patients with NP, 20 of whom (3.9%) had colonic involvement: 12 (2.3%) developed colonic fistulas, 6 (1.2%) had strictures, and 2 (0.4%) had ischemic colitis. In 50% of these patients, alcohol was the primary etiology of their pancreatitis, 18 (90%) had infected necrosis, and all patients eventually underwent percutaneous and/or endoscopic drainage. Mean patients age was 56 years (range 23 to 84 years); 80% were male. The most common associations with colonic involvement included male gender, obesity, alcohol as the primary etiology, infected necrosis, extensive pancreatic and extra-pancreatic involvement, and the need for drainage.

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Colonic fistulas were more likely to develop in the left colon (9 patients; 69.2%) and spontaneously close (7 patients; 53.8%). Of these patients, 4 were managed with over-the-scope clips and 2 required a diverting loop ileostomy. The researchers reported successful clinical outcomes in 11 patients (92%). 

Colonic strictures and ischemic colitis was managed conservatively in 3 patients (37.5%), with colonic stent placement in 3 patients (37.5%), with balloon dilation in 1 patient (12.5%), and surgically  in 1 patient (12.5%); successful clinical outcomes were reported in all 8 patients.

In the cohort, patients (0.97%) with pancreaticopleural fistulas (PPFs) were identified.  All patients were white and had exudative pleural effusions with amylase >1000 units/L. In addition, all patients had some form of imaging (computed tomography, magnetic resonance imaging, sinogram) performed to further delineate the site of pancreatic duct disruption and endoscopic retrograde cholangiopancreatography  with pancreatic duct stenting and/or chest tube placement was required in all patients. No surgical interventions were required. Only 1 patient died during the hospitalization. 

This study highlights the complexity of patients with NP and the importance of early recognition of possible colonic and pleural complications. These patients are best managed using a multidisciplinary approach at specialized centers with extensive experience in treating patients with NP. 

References

  1. Dirweesh A, Choo C, Amateau S, et al. Colon involvement in necrotizing pancreatitis-incidence, predictors and outcomes from a single tertiary care center. Poster presented at: 2019 ACG Annual Scientific Meeting and Postgraduate Course; October 25-30, 2019; San Antonio, Texas. Abstract P1819.
  2. Dirweesh A, Choo C, Amateau S, et al. Management of pancreaticopleural fistula in necrotizing pancreatitis:  a single tertiary care center experience. Poster presented at: 2019 ACG Annual Scientific Meeting and Postgraduate Course; October 25-30, 2019; San Antonio, Texas. Abstract P1820.