Internal pancreatic fistulas with pancreatic ascites and pancreatic pleural effusions: Recognition and management

Background: Internal pancreatic fistulas are well recognized complications of chronic pancreatitis. Methods: Six patients with internal pancreatic fistulas were treated over a period of 5 years from 1995 to 1999. Four patients presented with ascites, one patient presented with ascites and bilateral pleural effusion and the sixth patient presented with left-sided pleural effusion. Five patients were chronic alcoholics and in one patient the cause of pancreatitis was not clear. Although the serum amylase was mildly elevated the levels of amylase in the aspirated fluid were consistently elevated (more than 800 Somogyi units/100 mL), along with the level of proteins (> 3 g/100 mL), and on this basis the diagnosis was made. Endoscopic retrograde cholangiopancreatography (ERCP) demonstrated pancreatic ductal disruption in four cases. Initial treatment was conservative, consisting of nasogastric aspiration, nil per oral, antisecretory drugs, repeated paracentesis or thoracocenthesis and total parenteral nutrition (TPN). In two patients nasopancreatic drains (NPD) were placed across the disrupted pancreatic duct. Results: In one patient conservative treatment with NPD was successful, and the remaining five patients required surgical intervention. There was no mortality. Two patients developed surgery-related complications that were successfully managed, but they required an extended hospital stay. Conclusion: Internal pancreatic fistulas should be treated initially non-operatively; if this is not effective, operative therapy should be considered without delay.