Pancreatico-Colonic Fistula: A Case Report on Diagnosis and Management

Pancreatico-enteric fistulas are rare complications of chronic pancreatitis, with colonic involvement carrying particularly high morbidity and mortality. Early recognition and prompt surgical management are critical to improving outcomes. We present a case of a patient with necrotizing pancreatitis who developed a pancreatico-colonic fistula five months following initial hospitalization. A male in his 40s with a history of poorly controlled diabetes, hypertension, and gallstone pancreatitis (status post-cholecystectomy) was transferred to our tertiary care hospital in septic shock. Imaging revealed necrotizing pancreatitis with a splenic artery pseudoaneurysm, which was successfully embolized. CT-guided drainage of peripancreatic collections grew <i>Escherichia (E.) coli</i> (extended-spectrum beta-lactamase or ESBL), vancomycin-resistant Enterococcus (VRE), and <i>Streptococcus viridans</i>, requiring broad-spectrum antibiotics. The patient improved and was discharged after one month, but was lost to follow-up. Five months later, he was readmitted with persistent <i>Streptococcus</i> bacteremia. CT abdomen/pelvis with rectal contrast confirmed a pancreatico-colonic fistula at the splenic flexure. He underwent a robotic-assisted left colectomy with takedown of the fistula and end colostomy. Postoperatively, he recovered well, tolerated diet advancement, and was discharged on postoperative day seven. Pancreatico-colonic fistulas often result from spontaneous decompression of a pancreatic pseudocyst or abscess into adjacent bowel loops. Unlike other pancreatico-enteric fistulas, colonic involvement carries a significant risk due to the translocation of colonic flora and potential for sepsis. While small fistulas may respond to endoscopic closure, surgical resection remains the standard of care in patients with sepsis, large defects, or multiple perforations. Although uncommon, pancreatico-colonic fistula should be considered in patients with recurrent sepsis or bacteremia and a history of severe or necrotizing pancreatitis. Early imaging, surgical consultation, and definitive operative management are essential to improve outcomes.