Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Pancreatic fistulas: Clinical manifestations and diagnosis

Santhi Swaroop Vege, MD
Michael L Kendrick, MD
Section Editors
David C Whitcomb, MD, PhD
Stanley W Ashley, MD
Deputy Editor
Shilpa Grover, MD, MPH


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".)


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 [1]. 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):


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: Jun 15, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. Bassi C, Dervenis C, Butturini G, et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 2005; 138:8.
  2. Bassi C, Butturini G, Molinari E, et al. Pancreatic fistula rate after pancreatic resection. The importance of definitions. Dig Surg 2004; 21:54.
  3. Alexakis N, Sutton R, Neoptolemos JP. Surgical treatment of pancreatic fistula. Dig Surg 2004; 21:262.
  4. Yeo CJ, Cameron JL, Lillemoe KD, et al. Does prophylactic octreotide decrease the rates of pancreatic fistula and other complications after pancreaticoduodenectomy? Results of a prospective randomized placebo-controlled trial. Ann Surg 2000; 232:419.
  5. Muscari F, Suc B, Kirzin S, et al. Risk factors for mortality and intra-abdominal complications after pancreatoduodenectomy: multivariate analysis in 300 patients. Surgery 2006; 139:591.
  6. Ho HS, Frey CF. Gastrointestinal and pancreatic complications associated with severe pancreatitis. Arch Surg 1995; 130:817.
  7. Tsiotos GG, Smith CD, Sarr MG. Incidence and management of pancreatic and enteric fistulas after surgical management of severe necrotizing pancreatitis. Arch Surg 1995; 130:48.
  8. Connor S, Ghaneh P, Raraty M, et al. Increasing age and APACHE II scores are the main determinants of outcome from pancreatic necrosectomy. Br J Surg 2003; 90:1542.
  9. Kaman L, Behera A, Singh R, Katariya RN. Internal pancreatic fistulas with pancreatic ascites and pancreatic pleural effusions: recognition and management. ANZ J Surg 2001; 71:221.
  10. Ban D, Shimada K, Konishi M, et al. Stapler and nonstapler closure of the pancreatic remnant after distal pancreatectomy: multicenter retrospective analysis of 388 patients. World J Surg 2012; 36:1866.
  11. Fulcher AS, Capps GW, Turner MA. Thoracopancreatic fistula: clinical and imaging findings. J Comput Assist Tomogr 1999; 23:181.
  12. Lawrence C, Howell DA, Stefan AM, et al. Disconnected pancreatic tail syndrome: potential for endoscopic therapy and results of long-term follow-up. Gastrointest Endosc 2008; 67:673.
  13. Pelaez-Luna M, Vege SS, Petersen BT, et al. Disconnected pancreatic duct syndrome in severe acute pancreatitis: clinical and imaging characteristics and outcomes in a cohort of 31 cases. Gastrointest Endosc 2008; 68:91.
  14. Barkin JS, Ferstenberg RM, Panullo W, et al. Endoscopic retrograde cholangiopancreatography in pancreatic trauma. Gastrointest Endosc 1988; 34:102.
  15. Ceroni M, Galindo J, Guerra JF, et al. Amylase level in drains after pancreatoduodenectomy as a predictor of clinically significant pancreatic fistula. Pancreas 2014; 43:462.
  16. Devière J, Bueso H, Baize M, et al. Complete disruption of the main pancreatic duct: endoscopic management. Gastrointest Endosc 1995; 42:445.
  17. Bradley EL 3rd, Young PR Jr, Chang MC, et al. Diagnosis and initial management of blunt pancreatic trauma: guidelines from a multiinstitutional review. Ann Surg 1998; 227:861.
  18. Fulcher AS, Turner MA, Yelon JA, et al. Magnetic resonance cholangiopancreatography (MRCP) in the assessment of pancreatic duct trauma and its sequelae: preliminary findings. J Trauma 2000; 48:1001.
  19. Soto JA, Alvarez O, Múnera F, et al. Traumatic disruption of the pancreatic duct: diagnosis with MR pancreatography. AJR Am J Roentgenol 2001; 176:175.
  20. Ragozzino A, Manfredi R, Scaglione M, et al. The use of MRCP in the detection of pancreatic injuries after blunt trauma. Emerg Radiol 2003; 10:14.
  21. Cappeliez O, Delhaye M, Devière J, et al. Chronic pancreatitis: evaluation of pancreatic exocrine function with MR pancreatography after secretin stimulation. Radiology 2000; 215:358.