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Colopancreatic Fistula Following Screening Colonoscopy

Dirweesh, Ahmed MD1; Freeman, Martin MD1; Trikudanathan, Guru MD1

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doi: 10.14309/crj.0000000000000406
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CASE REPORT

A 62-year-old woman with a medical history of a left nephrectomy underwent screening colonoscopy under conscious sedation. The colon was described as redundant but endoscopically normal. She developed recurrent left abdominal pain after the procedure (managed empirically on several occasions as enteritis/diverticulitis, based on clinical symptoms and leukocytosis). A computed tomography scan, 3 months later, showed a complex collection involving the pancreatic tail and splenic flexure without an interim episode of pancreatitis (Figure 1). Fluid aspiration showed markedly elevated lipase/amylase concerning for pancreatic duct leak. Endoscopic retrograde cholangiopancreatography (ERCP) confirmed pancreatic duct leak managed by 3Fr × 13 cm single pigtailed Advantix (Boston Scientific, Natick, MA) stent and 5Fr × 3 cm Geenen stent (Cook Endoscopy, Bloomington, IN) (Figure 2). Although no definite fistulous communication to the colon was identified on fluoroscopic images, an immediate post-ERCP noncontrast computed tomography confirmed contrast in the left colon, suggesting a colopancreatic fistula (Figure 3). Her symptoms resolved after the procedure, and a follow-up ERCP confirmed resolution.

Figure 1.
Figure 1.:
Abdominal computed tomography scan showing complex collection involving pancreatic tail and splenic flexure (red arrow).
Figure 2.
Figure 2.:
Endoscopic retrograde cholangiopancreatography fluoroscopy image showing pancreatic duct leak.
Figure 3.
Figure 3.:
Postendoscopic retrograde cholangiopancreatography noncontrast computed tomography scan showing contrast in the left colon and confirming the existence of colopancreatic fistula (red arrow).

This case illustrates that patients with risk factors may develop a significant pancreatic injury after a colonoscopy. Likely mechanisms include traction on fibrous adhesions between the colon and pancreas, trauma by colonoscopy passage through the splenic flexure, and unnecessary abdominal pressure.1,2 The impact of previous abdominal or pelvic surgery on colonoscopy-related outcomes cannot be underestimated. Therefore, a careful review of the patient's relevant surgical history is essential to identify those at risk and to take preventive measures including avoiding/reducing endoscope looping, excessive force, and air insufflation.

DISCLOSURES

Author contributions: A. Dirweesh wrote the manuscript and reviewed the literature. G. Trikudanathan and M. Freeman edited the manuscript. G. Trikudanathan is the article guarantor.

Financial disclosure: M. Freeman consults with Boston Scientific and AbbVie.

Previous presentation: This case was presented at the American College of Gastroenterology Annual Scientific Meeting; October 25–30, 2019; San Antonio, Texas.

Informed consent was obtained for this case report.

REFERENCES

1. ASGE Standards of Practice Committee, Fisher DA, Maple JT, et al. Complications of colonoscopy. Gastrointest Endosc. 2011;74(4):745–52.
2. Rabeneck L, Paszat LF, Hilsden RJ, et al. Bleeding and perforation after outpatient colonoscopy and their risk factors in usual clinical practice. Gastroenterology. 2008;135(6):1899–906.
© 2020 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The American College of Gastroenterology.