1/27. Clinical significance of magnetic resonance cholangiopancreatography for the diagnosis of cystic tumor of the pancreas compared with endoscopic retrograde cholangiopancreatography and computed tomography.BACKGROUND: Cystic tumor of the pancreas has been investigated by a variety of imaging techniques. Magnetic resonance cholangiopancreatography (MRCP) is being widely used as a non-invasive diagnostic modality for investigation of the biliary tree and pancreatic duct system. The purpose of this study was to compare MRCP images with those of endoscopic retrograde cholangiopancreatography (ERCP) and computed tomography (CT) in order to clarify the diagnostic efficacy of MRCP for cystic tumor of the pancreas. methods: We retrospectively studied 15 patients with cystic tumor of the pancreas that had been surgically resected and histopathologically confirmed. There were five cases of intraductal papillary adenocarcinoma, five of intraductal papillary adenoma, two of serous cyst adenoma, two of retention cyst associated with invasive ductal adenocarcinoma and one of solid cystic tumor. RESULTS: In all cases MRCP correctly identified the main pancreatic duct (MPD) and showed the entire cystic tumor and the communication between the tumor and the MPD. On the other hand, the detection rate by ERCP of the cystic tumor and the communication between the cystic tumor and the MPD was only 60%. Although the detection rates by CT for the septum and solid components inside the cystic tumor were 100 and 90.0%, respectively, those of MRCP for each were 58.3 and 20.0%. CONCLUSION: MRCP is capable of providing diagnostic information superior to ERCP for the diagnosis of cystic tumor of the pancreas. Although MRCP may provide complementary information about the whole lesion of interest, the characteristic internal features of cystic tumor of the pancrease should be carefully diagnosed in combination with CT.- - - - - - - - - - ranking = 1keywords = tree (Clic here for more details about this article) |
2/27. False aneurysm of the pancreaticoduodenal artery complicating therapeutic endoscopic retrograde cholangiopancreatography.A 76-year-old woman underwent two endoscopic retrograde cholangiopancreatography (ERCP) procedures for palliation of a carcinoma of the pancreas. At the first procedure a pre-cut sphincterotomy was performed because deep cannulation of the biliary tree was impossible. An endoscopic plastic biliary stent was inserted at the second ERCP. The patient developed abdominal pain and a post-procedure CT demonstrated a pseudoaneurysm. This was not present on the pre-procedure CT and was thought to arise from the pancreaticoduodenal artery as a complication of the pre-cut sphincterotomy. Visceral angiography confirmed the origin of the aneurysm from a branch of the inferior pancreaticoduodenal artery. The aneurysm was successfully embolised. To our knowledge, this is the first time that this complication has been reported.- - - - - - - - - - ranking = 1keywords = tree (Clic here for more details about this article) |
3/27. Pancreatic ductal adenocarcinoma associated with Potter type III cystic disease.Although polycystic liver disease (PLD) is known to be associated with autosomal dominant polycystic kidney disease, a finding of PLD with pancreatic ductal adenocarcinoma is extremely rare. We have experienced one such case of a ductal adenocarcinoma of the pancreas in a patient with Potter type III cystic disease of the liver and kidney. A 63-year-old man was admitted to our hospital because of obstructive jaundice. Six months previously, on admission to a local hospital for treatment of diabetes mellitus, he had been found to have polycystic disease of the liver and kidney. Ultrasound examination revealed dilatation of the intrahepatic bile duct and the common bile duct. blood tests showed an elevated total bilirubin level. Abdominal computed tomography scans and magnetic resonance imaging demonstrated polycystic lesions in the liver and the bilateral kidneys. Percutaneous transhepatic cholangio-drainage was performed, and fluorography of the biliary tree revealed obstruction of the lower common bile duct, causing jaundice. This appears to be a case of independent association of pancreatic ductal adenocarcinoma with polycystic disease of the liver and kidney. The patient's sister, who also had polycystic disease of the liver and kidney, had died of squamous cell carcinoma of the tongue. Although familial associations of carcinomas with polycystic liver disease may be extremely rare, they provide a perspective for the etiology of polycystic liver disease.- - - - - - - - - - ranking = 1keywords = tree (Clic here for more details about this article) |
4/27. Eosinophilic pancreatitis and increased eosinophils in the pancreas.Prominent eosinophilic infiltrates are an unusual finding in the pancreas. Eosinophilic pancreatitis is one rare etiology of pancreatic eosinophilia, but other described causes of eosinophilic infiltrates have also included pancreatic allograft rejection, pancreatic pseudocyst, lymphoplasmacytic sclerosing pancreatitis (LPSP), inflammatory myofibroblastic tumor, and histiocytosis X. In this study we describe the clinicopathologic features of three new cases of eosinophilic pancreatitis and conduct a retrospective 18-year institutional review of the myriad disease processes associated with pancreatic eosinophilia. In the files of the Johns Hopkins Hospital, <1% of all pancreatic specimens had been noted to show increased numbers of eosinophils. Eosinophilic pancreatitis itself was a rare etiology for pancreatic eosinophilia, with only one in-house case over the 18-year study period and two additional referral cases. Other disease processes associated with prominent eosinophilic infiltrates were more common and included pancreatic allograft rejection (14 cases), LPSP (5 of 24 total LPSP cases evaluated), inflammatory myofibroblastic tumor (4 cases), and systemic mastocytosis (1 case). patients with eosinophilic pancreatitis showed two distinct histologic patterns: 1) a diffuse periductal, acinar, and septal eosinophilic infiltrate with eosinophilic phlebitis and arteritis; and 2) localized intense eosinophilic infiltrates associated with pseudocyst formation. All three patients with eosinophilic pancreatitis had peripheral eosinophilia, and all had multiorgan involvement. One patient with LPSP also had marked peripheral eosinophilia, and 5 of 24 LPSP cases demonstrated prominent eosinophilic infiltrates in the gallbladder, biliary tree, and/or duodenum. Notably, not all of these patients with LPSP with prominent eosinophils in other organs had increased eosinophils in the pancreas itself. These results emphasize the infrequent nature of pancreatic eosinophilia and its multiple potential disease associations. True eosinophilic pancreatitis, although a fascinating clinicopathologic entity, is one of the rarest causes of pancreatic eosinophilia.- - - - - - - - - - ranking = 1keywords = tree (Clic here for more details about this article) |
5/27. Autofluorescence endoscopy images of pancreas cancer: report of a case.This is the first report of the observation of pancreas cancer with an autofluorescence endoscopic imaging system (excitation: 437 nm). A case of intraductal papillary adenocarcinoma of pancreas was presented. After pancreatectomy, the resected pancreas was used to test the endoscope (16Fr) in the pancreatic duct. The normal pancreatic duct was seen as light blue and the protruding cancerous lesion was observed as a dark red image. In previous studies, cancerous lesions of the gastrointestinal tract, bronchial tree and bile duct also appeared dark red when examined by autofluorescence endoscopy. In the pancreatic duct, the cancer lesion was also detected as dark red color.- - - - - - - - - - ranking = 1keywords = tree (Clic here for more details about this article) |
6/27. Second primary lesions in the biliary tree after successful resection of ampullary carcinoma.Two patients are described who had an adenocarcinoma at the site of the hepaticojejunostomy 5 and 15 years after pancreaticoduodenectomy for an ampullary adenocarcinoma. Both patients had symptoms and signs of biliary obstruction. Both tumors were identified by upper endoscopy and resected at laparotomy. In both patients the tumor was considered a new primary carcinoma rather than a recurrent or metastatic carcinoma. Evidence to support this was the finding of an intraepithelial component of the tumor in the resection specimens of both patients, the fact that the tumors were on the luminal side of the distal bile duct in both cases, lack of other evidence of recurrent or metastatic tumor, and the time interval between the pancreaticoduodenectomy and the development of the new tumor.- - - - - - - - - - ranking = 4keywords = tree (Clic here for more details about this article) |
7/27. Pancreatic pseudotumor with sclerosing pancreato-cholangitis: is this a systemic disease?OBJECTIVE AND METHOD: Primary sclerosing cholangitis (PSC) is a disease that predominantly affects the biliary tree, although the pancreas may also be affected. A review of the presenting features of all patients given a diagnosis of PSC at a single center was conducted. The aim was to clarify the presentation of patients with pseudotumor of the pancreas in this patient population. RESULTS: Seventy-two patients were diagnosed with PSC either by ERCP (63/72 = 88%) or by liver biopsy (9/72 = 12%). The diagnosis of PSC was made following referral for abnormal liver tests (67%), jaundice (17%), and acute cholangitis (5%). Inflammatory bowel disease (IBD) (60%), non-insulin-dependent diabetes mellitus (NIDDM) (13%), thyroid disease (8%), and pancreatic disease (7%) were the major coexistent extrahepatic diseases. Three patients, all with marked weight loss, who presented with jaundice, abdominal pain, and/or diarrhea were found to have a pancreatic mass at first presentation. Clinical and radiological findings suggested pancreatic malignancy, and only later was advanced sclerosing cholangitis identified. The biopsy of the pancreas in two of these three patients revealed chronic pancreatitis. The long-term follow-up and good clinical response to medical therapy confirmed lack of pancreatic malignancy. These three patients all had other evidence of systemic involvement: submandibular gland fibrosis and urethral stricture in one, fibromuscular dysplasia of the renal artery in another, and retroperitoneal fibrosis in the third. None had IBD. CONCLUSION: Pancreatic pseudotumor with sclerosing pancreato-cholangitis may be a manifestation of a systemic disease characterized by nonmalignant strictures and multifocal fibroinflammatory processes, unlike classical PSC.- - - - - - - - - - ranking = 1keywords = tree (Clic here for more details about this article) |
8/27. Use of percutaneous drainage to treat hepatic abscess after radiofrequency ablation of metastatic pancreatic adenocarcinoma.Radiofrequency ablation (RFA) is well described in the treatment of primary hepatic malignancies and colorectal carcinoma hepatic metastases. A known complication of RFA is the development of hepatic abscess. The management of hepatic abscesses subsequent to RFA for metastatic disease is not well described. A 49-year-old female with pancreatic adenocarcinoma underwent pancreaticoduodenectomy followed by adjuvant chemoradiation. Following 6 months' treatment, a new liver metastasis was identified. It remained stable for 6 months during additional chemotherapy and thereafter was treated with RFA. Three weeks after RFA, the patient presented with malaise and leukocytosis, and a CT scan demonstrated a large hepatic abscess at the site of the RFA. She remained febrile despite needle aspiration and intravenous antibiotics. A percutaneous drain was placed and the symptoms resolved. Contrast injection of the drain 4 weeks later demonstrated resolution of the abscess cavity but communication with the biliary tree. The drain was removed and the tract embolized with Gel-foam to prevent complications of biliary-cutaneous fistula. She remains well without evidence of abscess or disease recurrence. Thus, RFA can be used in treatment of limited isolated hepatic metastases from previously treated pancreatic adenocarcinoma. However, the incidence of hepatic abscess is increased due to bilioenteric anastomosis; extended antibiotic prophylaxis should be considered.- - - - - - - - - - ranking = 1keywords = tree (Clic here for more details about this article) |
9/27. Case report: serial percutaneous cholangioscopy with laser ablation for the management of locally recurrent biliary intraductal papillary mucinous tumor.We present a case of serial cholangioscopic laser fulguration of a biliary recurrence of pancreatic intraductal papillary mucinous tumor in a 76-year-old man. Through established percutaneous biliary drain tracts, the aseptic use of a standard 6.9 F ureteroscope and holmium laser fiber facilitated visual ablation within the biliary tree. Quarterly cholangioscopic laser ablation provided safe and effective local control without biliary infectious complications. This case appears to be the first treatment of recurrent intrabiliary intraductal papillary mucinous tumor by serial antegrade choledocoscopy and laser photocoagulation. Effective local control appears possible with minimal morbidity. Standard ureteroscopic equipment facilitates safe and efficient percutaneous antegrade choledocoscopy.- - - - - - - - - - ranking = 1keywords = tree (Clic here for more details about this article) |
10/27. Percutaneous transhepatic cholangiography. Problems in interpretation.The patient who presents with jaundice, regardless of the etiology, cannot be adequately examined by a gallbladder series and intravenous cholangiography. Clinical evaluation aided by laboratory analysis will not always differentiate between primary liver parenchymal disease and biliary tract obstruction. Percutaneous transhepatic cholangiography, when successfully performed, answers the question of whether the jaundice is due to primary liver parenchymal disease or due to biliary tract obstruction. The point to emphasize is that under no circumstances is it appropriate to presume any information if the biliary system is not entered and visualized successfully. The proper interpretation of the level of block can fall prey to the mistake of incomplete aspiration of the thick, inspissated bile in the obstructed biliary tree before injection of contrast material. The problem will be worsened by a peripheral entrance into the biliary system rather than a more central one. Gastrointestinal series should always be available to aid in identifying pathology at the entrace of the common bile duct into the duodenum. Lastly, identifying the etiology at the site of the block will require additional procedures. Selective visceral angiography has contributed greatly in this area. During the 20 years of clinical usage of percutaneous transhepatic cholangiography, we feel it has become the single examination capable of preventing unnecessary exploration of the jaundiced patient with primary liver parenchymal disease and the most useful potential source of practical information if laparotomy is necessary to correct biliary tract obstruction.- - - - - - - - - - ranking = 1keywords = tree (Clic here for more details about this article) |
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