chronic pancreatitis is an inflammatory condition that may result in progressive parenchymal damage and fibrosis .
the destruction of pancreatic tissue can lead to exocrine as well as endocrine dysfunction in addition to biliary , duodenal or gastric obstruction , pseudocysts , pancreatic ascites , pleural effusion , splenic or portal vein thromboses , splenic artery pseudoaneurysm , cancer and pancreatic fistulae .
pancreatic fistulae have been reported to involve the pleura , peritoneum , pericardium , and other peripancreatic organs ( i.e. , esophagus , stomach , duodenum , and colon ) .
this case report describes a pancreaticouretral fistula  an exceedingly rare complication of pancreatitis , manifested as a fistula between the pancreatic duct and the ureter .
a 69-year - old hispanic female with a history of recurrent episodes of pancreatitis and cholecystectomy presented with complaints of severe , sharp , and constant abdominal pain in the left upper quadrant ( luq ) and flank with radiation to the left lower quadrant ( llq ) .
the pain was associated with subjective fever , nausea , and nonbloody emesis and was exacerbated by oral intake .
the patient denied additional gastrointestinal or genitourinary disturbances , sick contacts , travel , or consumption of unusual food .
two months prior to presentation , she had an episode of pancreatitis complicated by pseudocyst formation along the greater curvature of the stomach , measuring 13  9.5  5.5 cm .
she underwent ultrasound - guided drainage of approximately 100 ml of cloudy fluid with subsequent placement of a 12-french pigtail catheter .
external bag drainage was continued for 2 weeks and removed once the drainage was minimal .
one day after catheter removal , the patient developed progressive abdominal discomfort , which prompted repeat evaluation .
. a computed tomography ( ct ) scan of the abdomen revealed a cystic structure with fistulous extension below the pancreas into the left para - aortic space .
the reading further commented on the presence of mild left hydronephrosis due to the passage of the ureter near a cluster of lymph nodes and cystic structures from the fistula below the pancreatic tail measuring 2.2  3.9  4.5 cm [ figure 1 ] .
coronal ct scan demonstrating pancreatic pseudocyst ( arrow ) extending toward the left renal collecting system magnetic resonance cholangiopancreatography ( mrcp ) was obtained to further evaluate the pancreatobiliary anatomy .
it demonstrated an abnormal pancreatic duct in the body and tail of the pancreas with a complex multiloculated pseudocyst extending anteriorly into the lesser sac , posteriorly and medially to the level of the left kidney with possible ureteral fistula formation , and mild left - sided hydronephrosis [ figures 2 and 3 ] .
an additional smaller fistula was noted to extend medially from the pseudocyst into a soft - tissue mass .
axial t2-weighted sequence demonstrating the proximity of the pancreatic pseudocyst ( arrow head ) and the ureter ( long arrow ) 3d mrcp shows a fistula ( long arrow ) between the pancreatic pseudocyst ( arrow head ) and left renal collecting system ( short arrow ) in an effort to optimize pancreatic drainage , a sphincterotomy was performed with pancreatic stent placement during an endoscopic retrograde cholangiopancreatography ( ercp ) .
additionally , a left retrograde pyelogram was performed to evaluate the level / degree of ureteral obstruction and further assess for the presence of a fistulous tract .
a fistulous tract was in fact visualized between the left renal pelvis ( at the level of an upper pole calyx ) and the pancreatic duct and a ureteral stent was placed to facilitate fistula closure [ figure 4 ] .
the patient was started on imipenem / cilastatin prophylaxis pending blood and pancreatic pseudocyst fluid cultures , which ultimately returned culture negative . left retrograde pyelogram demonstrating a fistulous tract between the left renal pelvis ( at the level of an upper pole calyx ) and the pancreatic duct .
a ureteral stent was placed to facilitate fistula closure the patient remained intolerant of oral intake and experienced pain , even after the placement of pancreatic and ureteral stents . in an effort to relieve compression of the stomach by the pseudocyst and to facilitate eating , she underwent a successful pancreatic cyst gastrostomy . following the procedure , the patient attained symptomatic relief and oral intake was successfully resumed .
a left retrograde pyelogram was repeated after 2 months demonstrating no evidence of a residual fistulous tract [ figure 5 ] .
left retrograde pyelogram , repeated 2 months after initial intervention for puf , demonstrating no evidence of a fistulous tract
pancreaticoureteral fistulae ( puf ) are exceedingly rare . upon reviewing the literature only two case reports were identified . however , unlike our case , those fistulae evolved following traumatic injury to the ureter or pancreatic duct .
no reports were found to describe puf as a complication of chronic pancreatitis . in trauma related cases , pancreatic fistula most likely form secondary to persistent leakage of pancreatic secretions from a disrupted pancreatic duct .
many etiologies , including pancreatitis , trauma , biopsy , or surgery , can result in pancreatic duct disruption .
one proposed etiology for the evolution of a puf in our patient may involve recurrent inflammatory infiltrate progressively eroding surrounding structures and intimately extending into the retroperitoneal space .
ercp , mrcp , ct scan , and fistulography are often the main imaging studies implemented .
ercp was found to be 100% sensitive and specific in the diagnosis of pancreatic ductal rupture in one prospectively study and was superior to ct scan and mrcp , which are reported to detect pancreatic duct abnormalities with similar accuracy .
in addition to the common complications of pancreatic fistulae , complications specific for puf can include metabolic abnormalities ( hyperchloremic metabolic acidosis , electrolytes imbalance ) , urological complications ( chemical cystitis , urethritis , hematuria , urinary tract infection , and bladder stones ) , and reflux pancreatitis .
metabolic complications are due to a loss of alkaline exocrine pancreatic secretions in the urine while pancreatic enzymes secreted in the urine may cause urological complications . up to 50% of internal pancreatic fistulas and 70% to 90% of external pancreatic fistulas
for patients presenting with a main pancreatic duct dilatation , without ductal disruption or stricture , conservative therapy ( broad spectrum antibiotics , enteral nutrition , and correction of fluid and electrolyte imbalances ) should be pursued .
of note , enteral nutrition is associated with significantly higher closure rates and shorter time to closure , than parenteral nutrition .
additionally , somatostatin analog administration is reported to promote pancreatic fistula closure by decreasing the volume of fistulous tract output . if conservative measures fail or if the fistula becomes complicated by infection or bleeding , endoscopic or surgical interventions are warranted .
ercp is a safe and effective modality and can be considered the first - line therapy in the management of pancreatic fistulae .
early ercp and pancreatic stent insertion promote fistula resolution and may allow delay or avoidance of surgical measures .
due to their significant complication profile , surgical interventions should be reserved for cases not responsive to conservative measures .
a number of imaging modalities , such as ercp , mrcp , ct scan , or fistulography , can assist in the diagnosis of puf .
nonoperative modalities , including medical and endoscopic measures , may initially be pursued for the management of puf .
due to puf 's unclear etiology and possible variance of presentation , it is important for physicians to keep this rare complication of pancreatitis in mind while evaluating patients with recurrent pancreatitis , urinary symptoms , and/or imaging suggestive of abnormalities within the urinary collecting system and pancreas .
 context : chronic pancreatitis is an inflammatory condition that may result in progressive parenchymal damage and fibrosis which can ultimately lead to destruction of pancreatic tissue . 
 fistulas to the pleura , peritoneum , pericardium , and peripancreatic organs may form as a complications of pancreatitis . 
 this case report describes an exceedingly rare complication , pancreaticoureteral fistula ( puf ) . 
 only two additional cases of puf have been reported . 
 however , they evolved following traumatic injury to the ureter or pancreatic duct . 
 no published reports describe puf as a complication of pancreatitis.case report : a 69-year - old hispanic female with a past medical history of cholecystectomy , pancreatic pseudocyst , and recurrent episodes of pancreatitis presented with severe , sharp , and constant abdominal pain . upon imaging , 
 a fistulous tract was visualized between the left renal pelvis ( at the level of an upper pole calyx ) and the pancreatic duct and a ureteral stent was placed to facilitate fistula closure . following the procedure , 
 the patient attained symptomatic relief and oral intake was resumed . 
 a left retrograde pyelogram was repeated 2 months after the initial stent placement and demonstrating no evidence of a persistent fistulous tract.conclusion:due to puf 's unclear etiology and possible variance of presentation , it is important for physicians to keep this rare complication of pancreatitis in mind , especially , when evaluating a patient with recurrent pancreatitis , urinary symptoms and abnormal imaging within the urinary collecting system and pancreas . 
Introduction
Case Presentation
Discussion
Conclusion
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