Pancreatic fluid collections (PFC), including pancreatic pseudocysts and walled-off pancreatic necrosis, are a known complication of severe acute pancreatitis. A majority of the PFCs remain asymptomatic and resolve spontaneously. However, some PFCs persist and can become symptomatic. Persistent PFCs can also cause further complications such as the gastric outlet, intestinal, or biliary obstruction and infection. Surgical interventions are indicated for the drainage of symptomatic sterile and infected PFCs. Management of PFCs has evolved from a primarily surgical or percutaneous approach to a less invasive endoscopic approach. Endoscopic interventions are associated with improved outcomes with lesser chances of complications, faster recovery time, and lower healthcare utilization. Endoscopic ultrasound-guided drainage of PFCs using lumen-apposing metal stents has become the preferred approach for the management of symptomatic and complicated PFCs.

Pancreatitis is one of the important medical conditions. Gastrointestinal (GI) complications of pancreatitis are important and lead to significant morbidity and mortality. Diagnosis of these complications is difficult and may require a strong clinical suspicion coupled with various imaging features. This review provides an extensive update of the whole spectrum of GI complication of pancreatitis, both acute and chronic, from inflammation, ischemia, and necrosis to obstruction, perforation, and GI fistulae. The focus is on the clinical and imaging features of this less commonly described aspect of pancreatitis.

Pancreaticocolonic fistula (PCF) is an exceedingly rare complication of severe acute pancreatitis (SAP) and has primarily been treated surgically, but a few reported cases are successfully treated with nonsurgical methods.

A 32-year-old male presented to our hospital with chief complaints of sharp and persistent left upper quadrant abdominal pain radiating to the back.

Computed tomography showed a pancreatic pseudocyst replacing a majority of the pancreatic parenchyma and PCF that formed between the pancreas and the colon. However, the final diagnosis of PCF was confirmed by drainage tube radiograph, which revealed extravasation of contrast from the tail of the pancreas into the colon.

A therapeutic strategy of enteral nutrition (EN) was applied.

The patient responded well to the treatment. No complication and recurrence were reported during 2-year follow-up.

This case highlights the role of EN in the treatment of PCF secondary to SAP. To the best of our knowledge, this is the first case of PCF that treated successfully with EN, rather than surgical or endoscopic intervention.

Activated pancreatic enzymes due to pancreatitis track along anatomic fascial planes and result in digestion of the surrounding tissues and pseudocyst formation. Pancreatic pseudocysts can cause variable complications in some cases. Abdominal contrast-enhanced CT scan can provide a valuable method to identify pancreatic pseudocyst and its related complications, especially in evaluating the adjacent vascular involvement. Splenic arterial pseudoaneurysm ruptured into pancreatic pseudocyst together with fistulous communication with the colon is a very rare condition. So, here we report such an additional case with abruptly acute lower gastrointestinal bleeding on his admission, who was finally diagnosed to be splenic arterial pseudoaneurysm ruptured into pancreatic pseudocyst coexisting with fistula to the colon by contrast-enhanced CT scan and treated successfully by urgent surgery.

Colonic involvement in acute pancreatitis is associated with high mortality. Diagnosis of colonic pathology complicating acute pancreatitis is difficult. The treatment of choice is resection of the affected segment. The aim of this study is to evaluate the feasibility of aggressive surgical approach when colonic complication is suspected. Retrospectively, 8 patients with acute necrotizing pancreatitis and colonic complications (2006-2010) were reviewed. Eight patients with acute necrotizing pancreatitis requiring colonic resection were evaluated. Presentation was varied, including rectal bleeding (2), clinical deterioration during severe pancreatitis (4), colonic contrast leak on CT scan (1) and large bowel obstruction (1). Typically, patients with severe acute pancreatitis had colonic pathology obscured and unrecognized initially because of the ongoing, fulminant inflammatory process. All eight patients underwent Sub-total colectomy & ileostomy for suspected imminent or overt ischemia/perforation, based on the outer aspect of the colon. There was one mortality due to severe sepsis and multiorgan dysfunction syndrome. All other patients recovered well and later underwent closure of the stoma. Recognition of large bowel involvement may be difficult because of nonspecific symptoms or be masked by the systemic features of a critical illness. Clinicians should be aware that acute pancreatitis may erode or inflame the large bowel, resulting in lifethreatening colonic necrosis, bleeding or perforation. In our series of eight patients, we observed that mortality can be reduced by this aggressive surgical approach. We recommend a low threshold for colonic resection due to unreliable detection of ischemia or imminent perforation by outside inspection during surgery for acute necrotizing pancreatitis.

The advent of computed tomographic scan with its wide use in the evaluation of acute pancreatitis has opened up a new topic in pancreatology i.e. fluid collections. Fluid collections in and around the pancreas occur often in acute pancreatitis and were defined by the Atlanta Symposium on Acute Pancreatitis in 1992. Two decades since the Atlanta Conference additional experience has brought to light the inadequacy and poor understanding of the terms used by different specialists involved in the care of patients with acute pancreatitis when interpreting imaging modalities and the need for a uniformly used classification system. The deficiencies of the Atlanta definitions and advances in medicine have led to a proposed revision of the Atlanta classification promulgated by the Acute Pancreatitis Classification Working Group. The newly used terms "acute peripancreatic fluid collections," "pancreatic pseudocyst," "postnecrotic pancreatic/peripancreatic fluid collections," and "walled-off pancreatic necrosis" are to be clearly understood in the interpretation of imaging studies. The current treatment methods for fluid collections are diverse and depend on accurate interpretations of radiologic tests. Management options include conservative treatment, percutaneous catheter drainage, open and laparoscopic surgery, and endoscopic drainage. The choice of treatment depends on a correct diagnosis of the type of fluid collection. In this study we have attempted to clarify the management and clinical features of different types of fluid collections as they have been initially defined under the 1992 Atlanta Classification and revised by the Working Group's proposed categorization.

Colonic necrosis, fistula and stricture are infrequent but potentially lethal complications of pancreatitis. As any individual unit will have only limited experience, this study aims to provide a structured, systematic appraisal of published experience to identify any consistent trends and disease patterns that may help in practical management.

A computerized search of the MEDLINE databases for the period January 1950 through January 2006 yielded 43 articles. Pooled extracted data were examined for type of pancreatitis and colonic complications, method and time of diagnosis, treatment and outcome.

43 reports provided pooled data on 97 patients. Colonic complications were more frequent in severe disease, occurring in 15%. The principal presentations were necrosis, fistula and stricture. All episodes of colonic necrosis complicated severe acute pancreatitis, were diagnosed operatively, presented at a median of 25 (1-55) days into the episode and were associated with a mortality of 54%. In contrast, stricture presented at a median of 50 (10-270) days. Surgical resection without anastomosis is the mainstay of management of necrosis. Trial of conservative management in a stable patient with a fistula may facilitate spontaneous closure.

This study highlights several consistent trends: preoperative diagnosis is difficult, colonic necrosis and fistula are rare complications principally of severe acute pancreatitis and they present either as ongoing abdominal sepsis or rectal bleeding. Surgical resection remains the mainstay of management. A high index of suspicion should be maintained in patients with severe acute pancreatitis, with ongoing sepsis and evidence of gastrointestinal blood loss.

Colonic involvement in pancreatic disorders is rare but potentially fatal. Extension of contiguous inflammation or neoplasm, autodigestive effects of enzymes, or dissection of a pseudocyst or abscess may involve the colon producing obstruction, perforation, hemorrhage, or abdominal pain.

Nine patients with pancreatic disease requiring colonic resection were identified. Cases included pancreatic abscess producing colonic necrosis (2). pancreatic carcinoma invading the colon (3). extension of pancreatitis producing a colonic stricture (3). and pseudocyst eroding into the splenic flexure (1). Presentation was varied, including rectal bleeding (2). clinical deterioration during severe pancreatitis (4). and large bowel obstruction (3). The 3 cases due to malignancy, 1 of which was recurrent, presented with primary large bowel symptoms suggesting intestinal obstruction rather than pancreatic disease. Typically, patients with severe acute pancreatitis had colonic pathology obscured and unrecognized initially because of the ongoing, fulminant inflammatory process.

Recognition of large bowel involvement may be difficult because of nonspecific symptoms or be masked by the systemic features of a critical illness. Colonoscopy, contrast x-rays, or CT scan may be vital in selected cases to detect underlying pathology. Clinicians should be aware that acute or chronic pancreatitis or pancreatic carcinoma may compress, erode, or inflame the large bowel, resulting in life-threatening colonic necrosis, bleeding, obstruction, or perforation.

Fistulization of pancreatic pseudocysts into surrounding viscera is a well-known phenomenon and usually requires surgical management. We report two cases of pancreatic pseudocysts that developed spontaneous fistulas to the colon with resulting fever and abdominal pain. The patients were managed nonoperatively with a combination of endoscopic drainage and antibiotics, and their pseudocysts and fistulas resolved. The patients have remained symptom-free for a mean of 14 months of follow-up.

Massive bleeding from a pancreatic pseudocyst is a rare condition that poses a diagnostic and therapeutic challenge. A 36-yr-old woman presented with acute pancreatitis due to gallstones. Twenty-two days later, she developed severe abdominal pain and hypotension. CT scan revealed hemorrhage into a pancreatic pseudocyst and a large amount of free blood in the peritoneal cavity. At laparotomy, 8 L of blood was evacuated from the peritoneal cavity and 14 units of blood were transfused. The gastroduodenal artery was found to be the cause of the bleeding and was undersewn. A pancreatic necrosectomy was performed and the cavity was packed. The packs were removed the following day. Postoperatively, pancreatic collections were aspirated under ultrasound guidance on three occasions. She was discharged 50 days after admission and had an open cholecystectomy 1 month later. She remains well 1 yr after surgery.

A better definition of a pseudocyst that clearly separates it from acute fluid collection, improvements in imaging studies, and a better understanding of the natural history of pseudocysts have changed the concepts regarding their management. The old teaching that cysts of more than 6 cm in diameter that have been present for 6 weeks should be drained is no longer true. Indications for drainage are presence of symptoms, enlargement of cyst, complications (infection, hemorrhage, rupture, and obstruction), and suspicion of malignancy. The available forms of therapy include percutaneous drainage, transendoscopic approach, and surgery. The choice of procedure of depends on a number of factors, including the general condition of the patient; size, number, and location of cysts; presence or absence of communication of the cyst with the pancreatic duct; presence or absence of infection; and suspicion of malignancy. Expertise of the radiologist and the endoscopist is also a major deciding factor in the choice of therapy. Percutaneous catheter drainage is safe and effective and should be the treatment of first choice in poor-risk patients, for immature cysts, and for infected pseudocysts. Contraindications include intracystic hemorrhage and presence of pancreatic ascites. For mature cysts, in skilled endoscopic drainage should be given the first preference. It is less invasive, less expensive, and easier to perform with better outcomes in smaller pseudocysts and pancreatic head pseudocysts. Endoscopic expertise is limited, however, and at present endoscopic drainage cannot be advocated as the procedure for general use. In the absence of endoscopic expertise, percutaneous catheter drainage is the procedure of choice. Surgical treatment has been the traditional approach and is still the preferred treatment in most centers. Multiple pseudocysts, giant pseudocysts, presence of other complications related to chronic pancreatitis in addition to pseudocyst, and suspected malignancy are best managed surgically. Surgery is also the backup management in the event that percutaneous or endoscopic drainage fails. Because radiologic diagnosis of pseudocyst may be inaccurate in 20%; it is imperative to be sure that the cystic structure is not a neoplasm before percutaneous or endoscopic drainage. There have been no prospective, randomized trials that have evaluated the results of the three major modalities of therapy (percutaneous, endoscopic, and surgical), and before one can definitely recommend percutaneous drainage or endoscopic approach as the preferred initial mode of therapy, further studies are needed.

Lower gastrointestinal bleeding ranges from occult blood loss to massive hemorrhage and shock. There are many causes but diverticulitis and angiodysplasia remain the most common sources of major hemorrhage. This article emphasizes the cause and evaluation of moderate to severe acute lower gastrointestinal bleeding.