Pancreatic fistulas: Clinical manifestations and diagnosis
- Santhi Swaroop Vege, MD
Santhi Swaroop Vege, MD
- Professor of Medicine
- Mayo Clinic
- Michael L Kendrick, MD
Michael L Kendrick, MD
- Associate Professor of Surgery
- Mayo Clinic College of Medicine
- Section Editors
- David C Whitcomb, MD, PhD
David C Whitcomb, MD, PhD
- Section Editor — Pancreatic Diseases
- Professor of Medicine
- University of Pittsburgh School of Medicine
- Stanley W Ashley, MD
Stanley W Ashley, MD
- Section Editor — Pancreatic and Hepatobiliary Surgery
- Chief Medical Officer and Senior Vice President for Clinical Affairs
- Brigham and Women’s Hospital
- Frank Sawyer Professor of Surgery
- Harvard Medical School
A pancreatic fistula is characterized by leakage of pancreatic fluid as a result of disruption of pancreatic ducts. Disruption of pancreatic ducts can occur following acute or chronic pancreatitis, pancreatic resection, or trauma. Leakage of pancreatic secretions can cause significant morbidity due to malnutrition, skin excoriation, and infection.
The epidemiology, pathogenesis, clinical features, and diagnosis of pancreatic fistulas will be reviewed here. The prevention and management of pancreatic fistulas are discussed in detail, separately. (See "Surgical resection of lesions of the head of the pancreas", section on 'Prevention' and "Surgical resection of lesions of the body and tail of the pancreas", section on 'Postoperative pancreatic fistula' and "Pancreatic fistulas: Management".)
DEFINITION AND CLASSIFICATION
A pancreatic fistula (PF) is defined as an abnormal connection between the pancreas and adjacent or distant organs, structures, or spaces.
PFs are classified as internal if the pancreatic duct communicates with the peritoneal or pleural cavity or another hollow viscus and external if the pancreatic duct communicates with the skin. PFs can also be classified based upon the underlying disease process and the immediate predisposing cause (table 1).
According to the International Study Group for Pancreatic Fistulas (ISGPF), a postoperative PF is defined as an external fistula with a drain output of any measurable volume after postoperative day 3 with an amylase level greater than three times the upper limit of the normal serum value . Based on the clinical impact of the fistula on the patient's hospital course and outcome, postoperative PFs are graded as follows (table 2) (see 'Clinical manifestations' below):
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- DEFINITION AND CLASSIFICATION
- ETIOLOGY AND RISK FACTORS
- CLINICAL FEATURES
- Clinical manifestations
- - Internal fistulas
- - External fistulas
- Chest radiographs
- Diagnostic evaluation
- - Abdominal computerized tomography
- - Laboratory tests
- - Assessment of the pancreatic duct
- DIFFERENTIAL DIAGNOSIS