Endoscopic Ultrasound in the Diagnosis of Pancreatoduodenal Groove Pathology: Report of Three Cases and Brief Review of the Literature

The pancreatoduodenal groove is a small area where pathologic processes involving the distal bile duct, duodenum, pancreatic head, ampulla of Vater, and retroperitoneum converge. Despite great advances in imaging techniques, a definitive preoperative diagnosis is challenging because of the complex anatomy of this area. Therefore, surgical intervention is frequently required because of the inability to completely exclude malignancy. We report 3 cases of patients with different groove pathologies but similar clinical and imaging presentation, and show the essential role of endoscopic ultrasound (EUS) in making a specific preoperative diagnosis, excluding malignancy in the first case, changing diagnosis in the second case, and confirming malignancy in the third case. EUS was a fundamental tool in this cohort of patients, not only because of its ability to provide superior visualization of a difficult anatomical region, but because of the ability to guide precise, real-time procedures, such as fine-needle aspiration.

Groove Pancreatitis: Endoscopic Treatment via the Minor Papilla and Duct of Santorini Morphology

BACKGROUND/AIMS: Groove pancreatitis (GP) is an uncommon disease involving the pancreaticoduodenal area. Possible pathogenesis includes obstructive pancreatitis in the duct of Santorini and impaired communication with the duct of Wirsung, minor papilla stenosis, and leakage causing inflammation. Limited data regarding endoscopic treatment have been published. METHODS: Seven patients with GP receiving endoscopic treatment were reviewed. The morphology of the pancreatic duct was evaluated by a pancreatogram. Endoscopic dilation of the minor papilla and drainage of the duct of Santorini were performed. RESULTS: There were two pancreatic divisum cases, one ansa pancreatica case and four impaired connections between the duct of Santorini and the main pancreatic duct. Three to 31 sessions of endoscopy, with 2 to 24 sessions of transpapillary stenting and dilation, were performed. Interventions through the minor papilla were successfully performed in six of seven cases. The pancreatic stenting duration ranged from 2 to 87 months. Five patients with evidence of chronic pancreatitis (CP) tended to receive more endoscopic interventions than did the two patients without CP (2–24 vs 2, respectively) for GP and other complications associated with CP. CONCLUSIONS: Disconnection or impairment of communication between the ducts of Santorini and Wirsung was observed in all cases of GP. No surgery was required, and endoscopic minor papilla dilation and drainage of the duct of Santorini were feasible for the treatment of GP.

Groove Pancreatitis Masquerading as Pancreatic Carcinoma—Detected on 18F-FDG PET/CT / 대한핵의학회잡지

Groove pancreatitis is a rare form of chronic pancreatitis that affects the groove area adjacent to the second part of the duodenum. Clinical and biochemical features often overlap with other subsets of chronic pancreatitis, while the imaging features resemble that of carcinoma of the head of pancreas. We present a 38-year-old man with abdominal pain, nausea, vomiting, and loss of weight who underwent ¹⁸F-FDG PET/CT to rule out a pancreatic malignancy. PET/CT imaging features of groove pancreatitis are distinct from the other subsets of chronic pancreatitis, such as alcoholic and autoimmune pancreatitis, and helpful in the diagnosis and planning further management of the patient.

Pancreatitis autoinmune: sospecha, diagnóstico diferencial y manejo / Autoimmune pancreatitis: suspicion, differential diagnosis and management

Autoimmune pancreatitis was described only in the second half of the last century. Two types of the disease have been identified: Type 1; Lymphoplasmacytic sclerosing pancreatitis (LPSP), and Type 2, idiopathic duct centric pancreatitis (IDCP). Type 1 AIP is characterized by IgG4 positive lymphoplasmacytic infiltration, storiform periductal fibrosis and obstructive venulitis. It is frequently associated with other autoimmune diseases, it forms part of a systemic IgG4 dependent autoimmune disease, with a tendency of recurrence or progressive pancreatic damage in about 30 percent of the cases. In Type 2, histology reveals ductal destruction by granulocytic epithelial lesions. This type is considered as a pancreas-specific disease, the only association observed is with inflammatory bowel disease. After a successful treatment, recurrence of this disease is an exception. The basis of the diagnosis of AIP is serology and imaging methods. Computed Tomography (CT) scan and magnetic resonance have a good sensibility in the differential diagnosis of pancreatic lesions. Endosonography (EUS) with fine-needle aspiration (FNA) would be the best method to exclude pancreatic cancer. However, its limited accessibility in Chile and high costs make its use rather exceptional. The treatment of AIP is steroids, 0.5-1 mg/kg/day Prednisone for a relatively short period, without the need of permanent treatment in most cases. While possibility of recurrence or progressive pancreatic damage exists, the prognosis is generally good.

La pancreatitis autoinmune es una enfermedad descrita en la segunda mitad del siglo pasado. Se diferencian dos tipos, la pancreatitis esclerosante linfoplasmocítica (PELP-Tipo 1) y la pancreatitis idiopática conducto-destructivo (PICD-Tipo 2). El Tipo 1 está caracterizado por infiltración linfoplasmocitaria por células IgG4 positivas, fibrosis periductal y venulitis obstructiva. Se asocia con otras enfermedades autoinmunes, probablemente forma parte de una enfermedad sistémica IgG4 dependiente, clínicamente tiene la tendencia de recaídas o progresión del daño pancreático en 30 por ciento de los casos. En el Tipo 2 se ve la destrucción de conductos por lesiones granulocíticas epiteliales, considerada como enfermedad específica del páncreas, se asocia sólo con enfermedad inflamatoria intestinal. Después de su recuperación, la recaída es una excepción. El diagnóstico de la PAI se basa en métodos serológicos y morfológicos. Tomografía computada y resonancia nuclear magnética son de buen rendimiento en el diagnóstico diferencial de las enfermedades pancreáticas. Endosonografía con biopsia con aguja fina sería el mejor método para descartar cáncer de páncreas; su disponibilidad en Chile es más bien de excepción. El tratamiento es prednisona 0,5- 1,0 mg/kg/día por un período relativamente corto, sin necesidad de tratamiento de mantención en la gran mayoría de los casos. El pronóstico es bueno, aunque existe posibilidad de recaída o progresión hacia la cronicidad.

A Case of Groove Pancreatitis with a Characteristic Pathologic Feature / 대한소화기학회지

Groove pancreatitis is a rare form of chronic pancreatitis in which scarring is found mainly in the groove between the head of the pancreas, duodenum, and common bile duct. The pathogenesis of groove pancreatitis is still unclear but seems to be caused by the disturbance of pancreatic outflow through Santorini duct. It is often difficult to differentiate preoperatively between groove pancreatitis and pancreatic head carcinoma. Whereas conservative management is effective, some patients with duodenal obstruction may undergo Whipple's operation. A few case of groove pancreatitis have been reported in Korea, and they were diagnosed only by clinical and radiological features. We experienced a case of groove pancreatitis who needed a surgical management because of severe duodenal obstruction. We report the case with a review of its characteristic pathologic findings.