Characteristic Findings of Endoscopic Retrograde Cholangiopancreatography in Autoimmune Pancreatitis

BACKGROUND/AIMS: Diffuse or segmental irregular narrowing of the main pancreatic duct (MPD), as observed by endoscopic retrograde cholangiopancreatography (ERCP), is a characteristic feature of autoimmune pancreatitis (AIP). METHODS: ERCP findings were retrospectively examined in 40 patients with AIP in whom irregular narrowing of the MPD was detected near the orifice. The MPD opening sign was defined as the MPD within 1.5 cm from the orifice being maintained. The distal common bile duct (CBD) sign was defined as the distal CBD within 1.5 cm from the orifice being maintained. Endoscopic findings of a swollen major papilla and histological findings of specimens obtained from the major papilla were examined in 26 and 21 patients, respectively. RESULTS: The MPD opening sign was detected in 26 of the 40 patients (65%). The distal CBD sign was detected in 25 of the 32 patients (78%), which showed stenosis of the lower bile duct. The patients who showed the MPD opening sign frequently showed the distal CBD sign (p=0.018). Lymphoplasmacytic infiltration, but not dense fibrosis, was histologically detected in biopsy specimens obtained from the major papilla. CONCLUSIONS: On ERCP, the MPD and CBD adjacent to the major papilla are frequently maintained in patients with AIP involving the pancreatic head. These signs are useful for diagnosing AIP on ERCP.

Gastric Duplication Cyst with Ectopic Pancreas in a Child / 대한소화기학회지

No abstract available.

Neoplasia mucinosa intraductal del páncreas: [revisión] / Intraductal papillary mucinous neoplasm of the pancreas: [review]

Intraductal papillary mucinous neoplasm of the pancreas is characterized by a dilatation of the main pancreatic duct and/or secondary ducts, mucin production and the absence of ovarian ¡ike struma. The symptoms are non-specific and often the diagnosis is incidental. The treatment of choice is surgery, since these tumors may become malignant. The prognosis depends on the type of lesion, whether the excision is complete and lymph node involvement. The aim of this review is to analyze the clinical, diganostic, therapeutic and pathological characteristics of this disease.

Primary Adenocarcinoma of the Minor Duodenal Papilla

A 70-year-old man was admitted to our institution due to aggravation of blood-sugar level control and because an abdominal CT showed dilatation of the main pancreatic duct. Upper gastrointestinal endoscopy revealed a flat elevated tumor with central ulceration in the second portion of the duodenum. Subsequent duodenoscopy for a more detailed examination showed that the tumor had originated in the minor duodenal papilla. A biopsy specimen showed moderately differentiated adenocarcinoma. Endoscopic retrograde pancreatography via the major duodenal papilla revealed a slightly dilated main pancreatic duct and obstruction of the accessory pancreatic duct. Endoscopic ultrasonography showed a hypoechoic mass in the minor duodenal papilla with retention of the muscularis propria of the duodenum. These findings suggest that the tumor existed only to a limited extent in the minor duodenal papilla, and that the tumor did not infiltrate into the pancreas. For treatment, pylorus-preserving pancreatoduodenectomy was performed, and histological findings revealed a well-differentiated adenocarcinoma that originated in the minor duodenal papilla. Primary adenocarcinoma of the minor duodenal papilla is extremely rare. Our case is the first report of primary adenocarcinoma of the minor duodenal papilla at an early stage with no infiltration into muscularis propria of the duodenum and pancreas.

A Case of the Pancreatic Duct Change after a Long-term Pancreatic Stenting in Pancreas Divisum and the Fine Structural Analysis of Occluded Pancreatic Polyethylene Stent / 대한소화기학회지

The pancreatic duct stenting is now recognized as the treatment option for a number of pancreatic disorders. Although the stent-induced ductal changes may result, there is little information regarding the frequency of these stent-induced changes in chronic pancreatitis. Pancreatic stents may occlude with time, but there is only little information available on the nature of the clogging process. Although a short-term efficacy of endoscopic pancreatic duct stenting has been proved, the long-term efficacy continues to be controversial. The aim of this study was to report a case of chronic pancreatitis with pancreatolith after the incidental long-term pancreatic stenting for 3 years due to a pancreas divisum with acute pancreatitis. Also, this study described the analysis of the ultrastructural changes in the surface of an occluded pancreatic stent. A scanning and transmission electron microscopy showed an amorphous protein matrix in whole stent that arranged as a network in some areas but arranged as the layers in other areas. A variable number of bacteria of mixed species, calcium carbonate or calcium oxalate crystal, round leukocyte were scattered in the protein matrix. The yeast and plant material were seen in some part of the stent as well.

A Case of Santorinicele without Pancreas Divisum: Diagnosis with Multi-detector Row Computed Tomography

A santorinicele is defined as a focal cystic dilatation of the terminal portion of the dorsal pancreatic duct at the minor papilla. Most cases reported previously were associated with pancreas divisum and a santorinicele without pancreas divisum is known to be rare. We recently experienced a typical case of a santorinicele without pancreas divisum in a 67-yr-old woman with abdominal pain and hematochezia, subsequently proven to be the result of an ischemic colitis. The santorinicele was diagnosed incidentally with multi-detector row computed tomography using a minimum intensity projection technique, which clearly showed a cystic dilatation of the terminal portion of the dorsal pancreatic duct and a communication between the ventral and dorsal pancreatic ducts. This finding was also confirmed by a magnetic resonance cholangiopancreatography.

Pancreatico-pericardial fistula: a rare complication of chronic pancreatitis.

A 16-year-old boy presented with pericardial effusion, bilateral pleural effusion and mediastinal fluid collection. CT scan of abdomen revealed pancreatic calcification and a fistulous tract from a pseudocyst going along the inferior vena cava wall up to the pericardial cavity. After initial pericardiocentesis and pleurocentesis, lateral pancreatico-jejunostomy with Roux-en-Y loop was performed. The patient is well at 6 months follow up.

Membrana esofágica cervical (síndrome de Plummer-Vinson): remissão completa com reposição de ferro via oral / Total remission of Plummer-Vinson syndrome with oral iron intake

Racional - As membranas esofágicas são adquiridas e a deficiência de ferro parece dempenhar importante papel na patogênese.Relato de caso - Mulher de 20 anos com disfagia, emagrecimento de 5 kg, irritação de orofaringee odinofagia há 2 anos. Ao exame físico evidencia-se estudo radiográfico...

Estenose ductal pancreática por trauma: tratamento pela anastomose pancreatojejunal / Treatment of the traumatic pancreatic duct stenosis by pancreaticojejunostomy

Racional - Relatos demonstraram que a ressecção traumática do corpo do pâncreas tem apresentado como complicação tardia, estenose donóstio do ducto pancreático principal seccionado, que evolui para pancreatite crônica obstrutiva. Objetivo - Mostrar as vantagens de se realizara anastomose...

Santorinicele Containing a Pancreatic Duct Stone in a Patient with Incomplete Pancreas Divisum

Santorinicele, a focal cystic dilatation of the distal duct of Santorini, has been suggested as a possible cause of the relative stenosis of the accessory papilla, is associated with complete pancreas divisum, which results in acute episodes of pancreatitis or pain. This report describes a case of a santorinicele, which was initially detected by upper gastrointestinal endoscopy as a polypoid mass, in a patient with recurrent abdominal pain. The mass was subsequently proved to be a santorinicele containing a pancreatic duct stone associated with incomplete pancreas divisum on endoscopic retrograde pancreatography. To the best of our knowledge this is believed to be the first description of a santorinicele associated with these characteristic findings.

A pancreaticographic study of malnutrition-related diabetes mellitus.

Pancreatic involvement is considered to be the hallmark of malnutrition-related diabetes mellitus (MRDM). Of the 2 subgroups of the disease, fibrocalculous pancreatic diabetes (FCPD) is characterized by pancreatic calcification. The nature of pancreatic abnormalities in MRDM have not been studied extensively in Indian patients. The present study was designed to compare pancreatic abnormalities (exocrine and endocrine) including endoscopic retrograde pancreaticography in patients with FCPD and protein deficient pancreatic diabetes (PDPD), in relation to controls. Ten patients each of FCPD and PDPD were studied with regard to clinical features, biochemical exocrine and endocrine pancreatic responses, C-peptide response, islet cell antibody, and pancreatographic changes. Five normal pancreatograms were taken as control. Clinical and biochemical features in patient with FCPD and PDPD were as follows: pain in 8 and 2 patients, respectively; the mean duration of diabetes was similar in both groups (62.28 +/- 71.92 months V. 72 +/- 50.9 months); and faecal fat excretion and insulin requirements were comparable in both groups. The main pancreatic duct was dilated in 6 of 10 patient with FCPD and only 1 of 10 with PDPD on ultrasonography. On pancreatography the duct was dilated in 9 of 10 patients with FCPD and only 1 of 10 patients with PDPD. The number of side branches was reduced in all cases with MRDM; in those with FCPD, these were stunted and dilated while in PDPD side branches are thin and spastic. We conclude that pancreatic ductal changes involving the main duct and side branches are more frequent in patients with FCPD as compared to those with PDPD.

Magnetic resonance cholangiopancreatography: evaluation in 150 patients.

BACKGROUND AND AIMS: Magnetic resonance cholangiopancreatography (MRCP) is a non-invasive imaging technique for evaluating the biliary and pancreatic ducts. MRCP has reached a level of resolution and reliability where it may replace diagnostic endoscopic retrograde cholangio-pancreatography (ERCP). We analyzed the results of MRCP in adult patients with biliary or pancreatic disease, and compared the findings with those at surgery or on ERCP. METHODS: Data of 150 patients who underwent MRCP with both single slab and multislice rapid acquisition with relaxation enhancement sequences with half-fourier acquisition single-shot turbo spin echo techniques were analyzed. Patients were divided into four groups according to reason for referral for MRCP: obstructive jaundice (n = 65), chronic/acute pancreatitis (n = 25), screening prior to laparoscopic cholecystectomy (n = 20), and failed ERCP (n = 40). RESULTS: MRCP could accurately identify the level of biliary obstruction in 58 of 61 patients. Characterization of benign or malignant nature of a stricture was possible in 30 of 32 patients when findings of both MRCP and magnetic resonance imaging were analyzed together. MRCP revealed the morphology of the entire pancreatic duct in 13 of 15 patients having ductal changes on endoscopic retrograde pancreatography. CONCLUSION: MRCP has high sensitivity and specificity for detection of biliary dilatation, calculi, strictures and anatomical variants.

Neoplasia intraductal mucinosa de páncreas / Intraductal mucinous neoplasm of the pancreas

Antecedentes: La neoplasia intraductal mucinosa de páncreas (NIMP) es una enfermedad poco conocida cuyo pronóstico, tratamiento y evolución difieren del adenocarcinoma ductal pancreático. Objetivo: Presentar una serie de pacientes tratados por NIMP, haciendo principal referencia al diagnóstico y estrategia quirúrgica. Material y Método: Se analizaron retrospectivamente en el estudio todos los pacientes con diagnóstico anatomopatológico de NIMP en la pieza de resección tratados entre el año 1986 y el 2000. Asimismo se analizó la eficacia de los métodos diagnósticos y los resultados de la estrategia quirúrgica utilizada. Resultados: De los 70 pacientes con neoplasias quísticas del páncreas tratados durante el período, 9 fueron NIMP (12,8 por ciento), 3 eran mujeres y 6 eran varones. Fueron resecados 8 y el restante fue sometido a una derivación biliodigestiva por condiciones de irresecabilidad local. No hubo mortalidad operatoria. Tres pacientes fallecieron durante el período de seguimiento, uno por metástasis hepática, el otro por insuficiencia pancreática y el tercero por enfermedad local. No se observó recidiva local en aquellos pacientes con diagnóstico de displasia tratados con resección segmentaria. La colangiorresonancia fue el método diagnóstico preoperatorio más valioso. Conclusiones: La NIMP es una enfermedad con espectro clinicopatológico variado y su historia natural permanece aún desconocida. La cirugía de resección es el tratamiento de elección. Ante el diagnóstico de displasia están indicadas las resecciones limitadas y se reservan las resecciones ampliadas (pancreatectomía total) en los casos de transformación carcinomatosa por el alto índice de recidivas. La colangiorresonancia es esencial para definir la estrategia quirúrgica inicial

A case of minute intraductal papillary mucinous tumor of the pancreas presenting with recurrent acute pancreatitis

Intraductal papillary mucinous tumor (IPMT) of the pancreas, a lesion consisting of mucin-producing cells with neoplastic potential, is characterized by duct ectasia, mucin hypersecretion, often extensive papillary intraductal growth, varying degrees of cytologic atypia, and relatively indolent growth. The clinical presentation of IPMT of the pancreas is characterized by chronic or recurrent attacks of abdominal discomfort often in association with low level pancreatic enzyme elevations. Less commonly these lesions may be detected as asymptomatic radiographic abnormalities. Interestingly, a case of a minute IPMT (2 mm in height and 7 mm in length, adenoma) in the main pancreatic duct presenting with acute pancreatitis in a 55 year-old man has been reported in the Japanese literature. Recently, we also experienced a case of a minute IPMT in a branch pancreatic duct causing repeated bouts of acute pancreatitis in a 75 year-old man. A filling defect at the neck of the main pancreatic duct seen on an endoscopic retrograde pancreatogram performed after recovery of the second attack of acute pancreatitis led the patient to undergo an exploratory laparotomy. After a near-total pancreatectomy was carried out, a minute (3 x 7 mm) IPMT of borderline malignancy was discovered in a branch duct at the head portion near the pancreatic neck without any lesions in the main pancreatic duct. Surprisingly, despite the resective surgery the patient died of carcinomatosis 8.5 months after the operation. We herein report a case of a minute but aggressive IPMT of the pancreas with a review of the literature.

Endoscopic retrograde pancreatographic findings of pancreatic lipomatosis

Pancreatic lipomatosis is characterized by fatty infiltration or replacement of the pancreas, and has been associated with many conditions. We recently experienced two cases of pancreatic lipomatosis in patients with pancreatic pseudocyst and a case of lipomatosis in diabetes mellitus. In these patients, abrupt obstruction of the main pancreatic duct with smooth tapering is a typical endoscopic retrograde pancreatography (ERP) finding of pancreatic lipomatosis and must be differentiated with pancreatic carcinoma.