Case 273: Pancreatic Duct-to-Portal Vein Fistula with Secondary Portal Vein Pyophlebitis-A Rare Complication of Chronic Pancreatitis.

HistoryA 55-year-old man with a history of chronic pancreatitis secondary to chronic alcohol abuse presented to the hospital with acute abdominal pain, generalized weakness, weight loss, and pyrexia. A clinical examination revealed he was tender to touch in the upper abdomen. Laboratory tests revealed a serum alkaline phosphatase level of 370 U/L (6.1 µkat/L) (normal range, 30-130 U/L [0.5-2.2 µkat/L]), a lipase level of 172 U/L (2.9 µkat/L) (normal range, 0-60 U/L [0-1.0 µkat/L]), a C-reactive protein level of 159 mg/L (1514 nmol/L) (normal value, <8.0 mg/L [76.2 nmol/L]), and a white cell count of 7 × 109/L (normal range, [4-11] × 109/L). During the present admission, the patient underwent urgent CT for his acute symptoms. His relevant medical history included a hospital admission 2 months earlier for abdominal discomfort. Given his history of chronic pancreatitis, baseline abdominal MRI was performed to determine the cause of his symptoms and to assess the pancreas.

Aortic Bulge: A Possible Predictive Sign of Impending Aortoenteric Fistula.

PURPOSE: The purpose of this study is to introduce the aortic bulge sign, a finding observed retrospectively on computed tomography prior to the acute presentation of aortoenteric fistula, and to determine its interobserver reliability. METHODS: Following research ethics board approval, all cases of aortoenteric fistula at our institution occurring from 2011-2015 were identified retrospectively. All previous computed tomography images of patients who eventually developed aortoenteric fistula were reviewed by a single observer for the presence of a potentially predictive finding of fistulization, the aortic bulge sign. These previous images were then combined with age and sex matched controls into a case bank. Eight radiology residents and staff were instructed in observing the aortic bulge sign. These observers then reviewed the case bank in a blinded analysis to determine the interobserver reliability of this finding. RESULTS: Fourteen cases of aortoenteric were identified. The average patient age was 70.71 years with a male-to-female ratio of 11:3. Eleven patients had previous computed tomography images available for review. With blinded analysis by multiple observers, the aortic bulge sign was identified with greater than 80% agreement in six of 11 cases (66.67%). Fleiss' kappa was calculated at k = 0.60 (95% confidence interval 0.50-0.69), corresponding to moderate-to-substantial interobserver agreement. CONCLUSIONS: The aortic bulge sign has been retrospectively identified as a promising computed tomography finding of eventual aortoenteric fistula prior to acute presentation. Further study is required to determine the diagnostic value of this sign.

Endoscopic plombage with polyglycolic acid sheets and fibrin glue for gastrointestinal fistulas.

BACKGROUND AND STUDY AIMS: Gastrointestinal (GI) fistulas arise as adverse events of GI surgery and endoscopic treatment as well as secondary to underlying diseases, such as ulceration and pancreatitis. Until a decade ago, they were mainly treated surgically or conservatively. Bioabsorbable polyglycolic acid (PGA) sheets and fibrin glue, which are commonly used in surgical procedures, have also recently been used in endoscopic procedures for the closure of GI defects. However, there have only been few case reports about successful experiences with this approach. There have not been any case-series studies investigating the strengths and weaknesses of such PGA sheet-based treatment. In this study, we evaluated the clinical effectiveness of using PGA sheets to close GI fistulas. PATIENTS AND METHODS: Cases in which patients underwent endoscopic filling with PGA sheets and fibrin glue for GI fistulas at Kobe University Hospital between January 2013 and April 2018 were retrospectively reviewed. RESULTS: A total of 10 cases were enrolled. They included fistulas due to leakage after GI surgery, aortoesophageal/bronchoesophageal fistulas caused by chemoradiotherapy, or severe acute pancreatitis. The fistulas were successfully closed in 7 cases (70%). The unsuccessful cases involved a fistula due to leakage after surgical esophagectomy and bronchoesophageal fistulas due to chemoradiotherapy or severe acute pancreatitis. Unsuccessful treatment was related to fistula epithelization. CONCLUSION: Endoscopic plombage with PGA sheets and fibrin glue could be a promising therapeutic option for GI fistulas.

Imaging after Bariatric Surgery: When Interpretation Is a Challenge, from Normal to Abnormal.

Bariatric surgery has proven to be the most effective weight loss strategy in severe obesity. Imaging in the immediate postoperative period of bariatric surgery is not done routinely. However, it is helpful in the assessment of early and late complications, which are estimated to be present in < 1% of patients. In some cases, the imaging interpretation of anatomical outcomes and complications related to these procedures represents a challenge for surgeons and radiologists. The aim of this review is to describe the imagenologic findings after bariatric surgery and focuses on the findings of the most frequent procedures performed in Colombia such as laparoscopic sleeve gastrectomy, laparoscopic Roux-en-Y gastric bypass, and laparoscopic adjustable gastric banding. Contrasted CT scan and fluoroscopic studies have shown a high sensitivity in the early and late diagnosis of bariatric surgery complications, but in order to be able to appropriately identify these complications, it is important to be familiar with the normal or expected radiological findings.

Endoscopic Closure of Gastrointestinal Fistulae and Leaks.

The development of new endoscopic techniques, such as gastrointestinal (GI) stenting, full-thickness suturing, clip application, and use of tissue adhesives, has had a significant impact on management of GI fistulae. These techniques have shown promising results, but further study is needed to optimize the efficacy of long-term closure. The advancement of endoscopic techniques, including the use of the lumen apposing metal stent (LAMS), has allowed for the deliberate creation of fistula tracts to apply endoscopic therapy that previously could not be achieved. This article examines the rapidly evolving area of endoscopic fistula closure and its relationship to LAMS.

Rare Case of Cerebrospinal Fluid Proctorrhea Caused by Anterior Sacral Meningocele with Rectothecal Fistula.

BACKGROUND: Anterior sacral meningocele (ASM) leading to secondary rectothecal fistula is extremely rare, and to date only 5 such cases have been described in the world literature. CASE DESCRIPTION: We describe an uncomplicated case of a 52-year-old female patient presenting with cerebrospinal fluid leak from the anus who was investigated and found to have an ASM with rectothecal fistula. The ASM and rectothecal fistula were subsequently repaired using a posterior approach. Pertinent literature review, clinical findings, neuroimaging, and surgical management are described for these rare lesions. CONCLUSION: Early diagnosis and surgical disconnection of the fistulous tract led to satisfactory outcome in the present case and avoided the catastrophic complication of meningitis.

Respiratory-digestive tract fistula: two-center retrospective observational study.

Background Aerodigestive fistulae can be defined as abnormal communications between the gastrointestinal tract and the respiratory tract. Choking after meals, coughing, feeding difficulties, tachycardia, and persistent pneumonia are the main presentations. The aim of our study was to review our experience in the management of 27 cases of acquired aerodigestive fistulae of different types, levels, and management. Methods We conducted a retrospective observational study on 27 cases of fistulae between the respiratory and digestive tracts, which were managed in 2 hospitals in Saudi Arabia in the last 5 years. The patients comprised 16 females and 11 males, with a mean age of 29 years (range 17-67 years). Results The most common aerodigestive tract fistula was tracheoesophageal in 8 patients, followed by esophagobronchial in 6, and esophagopleural in 5. Four postendoscopic fistulae were included. The least common were gastropleural and esophagopulmonary fistulae. The most common etiologies were iatrogenic and esophageal cancer, and the least common was blunt chest trauma. The main presentations were fever, chocking after or during meals, and tachycardia. We used various modalities of treatment: conservative, cervical repair, thoracoabdominal repair, hybrid insertion of a T-tube, endoscopic esophageal stenting, and endoscopic clipping of the fistulous tract. During follow-up, 6 patients died due to advanced esophageal cancer in 5 and upper airway obstruction after iatrogenic tracheobronchial fistula in one. Conclusion Acquired aerodigestive fistula is a devastating condition that should be managed early and aggressively by a multidisciplinary team.

Intracavitary Contrast-Enhanced Ultrasound in the Management of Post-Surgical Gastrointestinal Fistulas.

The goal of this study was to investigate intracavitary contrast-enhanced ultrasound (IC-CEUS) measures in the management of post-surgical gastrointestinal (GI) fistula throughout detection, treatment and follow-up. From June 2010 to August 2016, patients who were administered ultrasound contrast agent (UCA) via a drainage tube for IC-CEUS were enrolled and retrospectively analyzed. They were suspected of having GI anastomotic fistulas or had been found to have fluid collections with ultrasound that were accompanied by abdominal pain or fever after surgical procedures. Forty-two patients met the inclusion criteria and were enrolled into this study. Twenty-two were confirmed to have GI fistulas confirmed by standard references. None were detected by conventional ultrasound. Although IC-CEUS successfully detected GI fistulas in 16 patients, it missed GI fistulas in 6 patients. One patient was misdiagnosed with a GI fistula. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of the diagnosis of GI fistulas by IC-CEUS were 72.7% (16/22), 95.0% (19/20), 94.1% (16/17), 76.0% (19/25) and 83.3% (35/42), respectively. Twenty peritoneal fluid collections in 14 patients were related to fistulas by IC-CEUS based on the distribution of ultrasound contrast agents. Additional drainage was performed in 14 fistula-related fluid collections. Eight GI fistulas were judged to be cured after IC-CEUS re-evaluation, and the drainage tubes were removed from these patients. In conclusion, IC-CEUS can greatly improve the ability to diagnose post-surgical GI fistulas and may also play an important role in interventional treatment and follow-up.

Diagnostic Accuracy of Sonography for Detection of a Fistula on the Birth Day in Neonates With an Imperforate Anus: Comparison of Diagnostic Performance Between Suprapubic and Perineal Approaches.

OBJECTIVES: To evaluate the diagnostic accuracy of sonography for detection of an internal fistula on the birth day in neonates with an imperforate anus and to compare the diagnostic performance between the suprapubic and perineal approaches. METHODS: We included 46 neonates with an imperforate anus (29 low type and 17 intermediate/high type) who underwent sonography by both the suprapubic and perineal approaches on the birth day. Thirty-nine neonates had internal fistulas, and 12 did not, as surgically proven. Two blinded radiologists evaluated the suprapubic and perineal sonograms for the presence of the internal fistula in consensus. A final diagnosis of the internal fistula was determined on the basis of the findings of both approaches. A receiver operating characteristic analysis was used to compare the diagnostic performance for detection of an internal fistula between the suprapubic and perineal approaches. RESULTS: The sensitivity, specificity, and accuracy of the final diagnosis based on the findings of suprapubic, perineal, and both approaches were 52.9%, 79.4%, and 79.4%; 75.5%, 75.5%, and 75.5%; and 58.7%, 78.3%, and 78.3%, respectively. The diagnostic performance of the perineal approach was significantly better than that of the suprapubic approach (P < .0001). CONCLUSIONS: The diagnostic accuracy of sonography for detection of an internal fistula on the birth day exceeded 75% in neonates with an imperforate anus, and sonography on the birth day is feasible. The perineal approach had superior diagnostic performance over the suprapubic approach. Thus, when evaluating an internal fistula by sonography, we recommend using the perineal approach in addition to the suprapubic approach.

Coloduodenal and enterocutaneous fistula in twins with Crohn´s disease.

We present the case of a pair of 45-year-old monozygotic twins (A and B) diagnosed with Crohn's disease (CD) at age 20 (A) and 22 (B) with similar presenting symptoms: diarrhea, fever and weight loss. Both of them had duodenal and ileocolonic disease (A2, L3+L4 according to Montreal classification); twin B also presented jejunal involvement and perianal disease (B1p). They received treatment with antibiotics, corticosteroids, 5-ASA, azathioprine and anti-TNF with a poor control of activity. They both developed a coloduodenal fistula that required surgery. Twin A developed the fistula 12 years after the first presentation; fistula closure with duodenorraphy and ileocolonic resection with gastrojejunostomy was performed. Twin B developed the fistula 22 years after the first presentation, and right colectomy, partial duodenectomy and duodenorraphy was carried out. Both developed an enterocutaneous fistula during the postoperative period. With intensive medical treatment, both twins remain asymptomatic.

Gastrointestinal Fistulization in Amebic Liver Abscess.

BACKGROUND: Liver abscess is a common deep seated abscess in children; amebic liver abscess is associated with more local complications. CASE CHARACTERISTICS: We report two preschool children presenting with short history of pain, fever and right upper quadrant pain. The abscess communicated with gastro-intestinal tract (ascending colon in case 1 and duodenum in case 2), and diagnosis of amebic liver abscess was confirmed by DNA PCR. OUTCOME: Both children were successfully managed with intravenous antibiotics and catheter drainage. MESSAGE: Gastrointestinal fistulization may be rarely seen in amebic liver abscess. Conservative management with antibiotics, catheter drainage and supportive care may suffice.

Digestive Tract Complications of Renal Cryoablation.

We report a case each of duodenorenal and colorenal fistula that arose after computed tomography-guided percutaneous cryoablation (PCA) for renal cell carcinoma and use imaging and endoscopic findings to analyze their causes and mechanisms. Both complications occurred though the edge of the iceball did not touch the intestinal wall, and patients' symptoms and fistula formation occurred several days after the PCA procedure. Based on imaging and endoscopy findings, we suspected the colorenal fistula resulted from bowel injury caused by ischemia from the occlusion of small vessels at the procedure's low temperature. Both cases were resolved conservatively without surgical intervention.