Severe Acute Pancreatitis with Complicating Colonic Fistula Successfully Closed Using the Over-the-Scope Clip System

Abstract

A 44-year-old man presenting to our hospital emergency room with abdominal pain was hospitalized for hyperlipidemic acute pancreatitis. A pig-tail catheter was placed percutaneously to drain an abscess on day 22. Although the abscess improved gradually and good clinical progress was seen, pancreatic duct disruption was strongly suspected and endoscopic retrograde cholangiopancreatography was performed on day 90. An endoscopic nasopancreatic drainage tube was placed, but even with concurrent use of a somatostatin analogue, treatment was ineffective. Surgical treatment was elected, but was subsequently postponed as the abscess culture was positive for extended-spectrum β-lactamase-producing Escherichia coli and methicillin-resistant Staphylococcus aureus. Drainage tubography showed a small fistula of the colon at the splenic flexure on day 140. Colonoscopy was performed on day 148. After indigo carmine had been injected, a fistula into the splenic flexure of the colon showed blue staining. The over-the-scope clip (OTSC) system was used to seal the fistula and complete closure was shown. A liquid diet was started on day 159 and was smoothly upgraded to a full diet. Following removal of the pancreatic stent on day 180, drainage volume immediately decreased and the percutaneous drain was removed. On day 189, computed tomography showed no exacerbation of the abscess and the patient was discharged on day 194. This case of colonic fistula caused by severe acute pancreatitis was successfully treated using the OTSC system, avoiding the need for an open procedure.

Keywords: Colonic fistula; Endoscopic treatment; Pancreatic duct disruption; Severe acute pancreatitis.

Fig. 1

a–c Abdominal CT showing exacerbation of the peripancreatic fluid collection and abscess.

Fig. 2

Drainage tubography showed a fistula of the colon at the splenic flexure (arrowhead).

Fig. 3

The fistula into the splenic flexure was a small erosion (a) that stained blue after indigo carmine injection (b). The OTSC clip was released and sealed the fistula (c).