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Chronic pancreatitis and significant alcohol use are common conditions and known risk factors for the development of pancreatic duct-portal vein (PD-PV) fistulas with a risk of subsequent liver necrosis accompanied by significant morbidity and mortality.

PD-PV fistulas can occur due to disruption of the PD and erosion of pancreatic enzymes into the wall of the PV. This is facilitated by the presence of a large pseudocyst (PC) in the vicinity of the PV, eventually creating a connection between the two structures.

Ductal anatomy should be evaluated with contrast enhanced CT and/or MRI when there is high clinical suspicion and a complex fluid density is visualized in the Portal vein on initial imaging. This will increase the odds of early identification of fistulization and subsequent planning for further management which is typically endoscopic or surgical depending on the severity of the presentation.