Spontaneous gastrointestinal (GI) fistula is an uncommon but serious complication of necrotising pancreatitis, associated with significant morbidity and mortality. Early identification is crucial, yet published data on its presentation and management remain limited.

We retrospectively analysed a prospectively maintained database of 146 patients with acute pancreatitis who developed pancreatic fluid collections. Clinical presentation, imaging findings and management outcomes of patients with pancreatoenteric fistula were reviewed.

Spontaneous pancreatoenteric fistula was identified in 5.3% of patients using contrast enhanced CT with oral/rectal contrast and/or gastrointestinal endoscopy. The most common clinical presentation was worsening or recurrent abdominal pain with intermittent fever, observed in 5 patients (50%). Gastrointestinal bleeding occurred in 4 patients (40%). Most patients were managed successfully with minimally invasive approaches: percutaneous drainage in 6 patients (60%) and EUS guided cystogastrostomy in 2 patients (20%). Only one patient required surgical intervention.

Spontaneous gastrointestinal fistula should be suspected in patients with necrotising pancreatitis who develop new or worsening abdominal pain, sepsis, or GI hemorrhage. Minimally invasive management including percutaneous drainage and EUS guided interventions forms the mainstay of treatment, while surgery should be reserved for patients who fail conservative management or show rapid clinical deterioration.