Tumor-associated focal chronic pancreatitis from invasion of the pancreatic duct by common bile duct carcinoma: radiologic–pathologic correlation

We report a case of tumor-associated focal chronic pancreatitis of the uncinate process of the pancreas. The chronic pancreatitis was secondary to stenosis of the main pancreatic duct from invasion by a common bile duct carcinoma. A feature distinguishing the chronic pancreatitis from pancreatic carcinoma was the localized dilatation of pancreatic duct branches evident in the focal lesion of the uncinate process.     

Pancreatic uncinate carcinoma: sonographic findings

BACKGROUND: Pancreatic carcinoma arising from the uncinate process (pancreatic uncinate carcinoma) is relatively rare. We wished to define its clinical manifestations and sonographic findings. METHODS: Clinical and sonographic data of eight cases were reviewed. RESULTS: The common bile duct and the pancreatic duct were not dilated until a very late stage. The lesion mimicked a mesenteric tumor in two cases. The superior mesenteric vessels were compressed anteriorly. Computed tomography was useful, not only for confirming the pancreatic uncinate origin of the lesion but also for determining precisely the mode of mesenteric vascular involvement. CONCLUSION: Knowledge of these unusual sonographic findings can determine the diagnostic strategy in pancreatic uncinate carcinoma.     

Sonographic evaluation of the pancreatic duct in normal children and children with pancreatitis.

We investigated the diameter of pancreatic duct using ultrasonography in 51 children with pancreatitis and age-matched healthy control children over a 5 year period. The diameters of pancreatic duct and pancreatic body were measured simultaneously by sonography. The mean ages of children with acute pancreatitis and chronic pancreatitis were 9.7 +/- 3.9 and 10.3 +/- 3.1 years, respectively (range, 1 to 8 years). The mean age of normal children was 9.6 +/- 5.3 years. A significant difference was found in diameter of the pancreatic duct between children with acute and chronic pancreatitis versus that of age-matched control. In addition, a significant difference in diameter of the pancreatic body was found between children with acute pancreatitis and age-matched controls, but there was no marked difference in diameter of the pancreatic body between normal persons and those with chronic pancreatitis. The mean diameters of the pancreatic duct in acute pancreatitis and chronic pancreatitis were 2.34 +/- 0.47 mm and 2.84 +/- 0.67 mm, respectively, which was greater than that of normal children (1.65 +/- 0.45 mm). Pancreatic ducts with diameters greater than 1.5 mm in children between 1 and 6 years, greater than 1.9 mm at ages 7 to 12 years, or greater than 2.2 mm at ages 13 to 18 years were significantly associated with the presence of acute pancreatitis. Thirty-two patients, including 25 with acute pancreatitis and 7 with chronic pancreatitis, underwent follow-up measurement of pancreatic duct and serum lipase examination on at least three occasions. A good correlation between the diameter of pancreatic duct and serum lipase level was found. Thus, ultrasonography of the pancreatic duct is valuable in diagnosis and monitoring of pancreatitis in children.     

Ultrasonic evaluation of the pancreatic duct

In a prospective ultrasound study of 253 patients, the lumen of the normal pancreatic duct of Wirsung could be demonstrated in 82% of the patients. The mean diameter of the normal pancreatic duct (of Wirsung) was 1.3 mm. The duct of Santorini occasionally could be demonstrated. A duct of Wirsung greater than 2 mm in diameter should be considered dilated. The pancreatic duct is dilated in most patients with acute pancreatitis, in some patients with chronic pancreatitis, and in some patients with pancreatic tumor.     

Transpapillary miniscopy and mini-biopsy of the pancreatic duct

This paper reports on the new combined examination of peroral transpapillary fine-caliber endoscopy (miniscope 0.5 mm in diameter) with mini-biopsy of the pancreatic duct in 10 patients and 19 surgical pancreas resection preparations. With this technique, endoscopic-retrograde inspection of the whole length of the pancreatic duct is possible without the need for papillotomy. In the case of pancreatic duct changes due to carcinoma of the pancreas, and chronic pancreatitis, the ductal lesions can be inspected. Furthermore, with the aid of a new mini-biopsy forceps (1.5 mm in diameter), material for histological evaluation can be much more efficiently obtained than was normally possible with conventional biopsy forceps (2.2 mm). This new endoscopic-bioptic technique promises to improve the diagnostic reliability in pancreatic duct lesions requiring clarification.     

Floating pancreatic duct concrements in chronic pancreatitis. Pain relief by endoscopic removal

This report describes 3 patients with chronic relapsing pancreatitis, floating pancreatic duct concrements between 4 and 6 mm in diameter, moderate to advanced ductal changes, and repeated severe attacks of pain during acute relapses over a period of several months. Immediate relief of pain was achieved in all 3 patients by endoscopic papillotomy aimed at widening the main pancreatic duct and subsequent extraction or spontaneous passage of pancreatic duct concrements. On the basis of our experience with the patients presented here, endoscopic papillotomy widening the main pancreatic duct may be useful in some patients with chronic pancreatitis and floating pancreatic duct concrements.     

Computed tomography and the dilated pancreatic duct: An ominous sign

The main pancreatic duct has been visualized with both ultrasound and computed tomography. A normal pancreatic duct has not been reported using CT, and controversy persists over whether a normal duct can be routinely imaged with ultrasound. The dilated pancreatic duct has always been associated with disease — usually pancreatitis or a proximal obstructing pancreatic carcinoma. In the patient with no clinical history or laboratory data suggesting pancreatitis, a dilated pancreatic duct implies a proximal tumor.     

Pancreatica magna aneurysm: rupture into the pancreatic duct

A 49-year-old black man had rupture of a pancreatica magna aneurysm into the pancreatic duct as an inflammatory consequence of chronic pancreatitis and pancreatic pseudocyst. It is the ninth reported case of splenic arterial branch rupture due to chronic pancreatitis and the seventh reported case due to chronic pancreatitis associated with pancreatic pseudocyst, and is presented to emphasize its importance as a possible cause of gastrointestinal bleeding.     

Fully covered self-expanding metal stents for refractory pancreatic duct strictures in chronic pancreatitis

Fully covered self-expanding metal stents (FC-SEMSs), which can be removed from the bile duct, have recently been used in the main pancreatic duct (MPD) in chronic pancreatitis. The aim of this study was to investigate the feasibility, safety, and efficacy of FC-SEMSs in painful chronic pancreatitis with refractory pancreatic strictures. The primary endpoints were technical success and procedure-related morbidity. Secondary endpoints were pain relief at the end of follow-up and resolution of the dominant pancreatic stricture at endoscopic retrograde pancreatography. Over 5 months, 10 patients with painful chronic pancreatitis and refractory dominant pancreatic duct strictures were treated with FC-SEMSs. All FC-SEMSs were successfully released and removed, although two stents were embedded in the MPD at their distal end and treated endoscopically without complications. Mild abdominal pain was noted in three patients after stent release. During treatment, pain relief was achieved in nine patients, but one continued to take morphine, because of addiction. Cholestasis developed in two patients and was treated endoscopically; no patient developed acute pancreatitis or pancreatic sepsis. After stent removal, the diameter of the narrowest MPD stricture had increased significantly from 3.5 mm to 5.8 mm. Patients were followed up for a mean of 19.8 months: two patients who continued drinking alcohol presented with mild acute pancreatitis; one patient developed further chronic pancreatic pain; and one had a transient pain episode. At the end of the study, nine patients no longer had chronic pain and no patients had required surgery. Endoscopic treatment of refractory MPD stricture in chronic pancreatitis by placement of an FC-SEMS appears feasible, safe, and potentially effective.     

Ultrasonographic demonstration of the pancreatic duct

During a 4-year period, 375 patients with clinically suggestive pancreatic disease were examined with gray scale ultrasound. In 14 patients, the pancreatic duct itself was demonstrated. All of these had clinical or laboratory evidence for, and radiologically or surgically proven, pancreatic duct obstruction. Etiology of the obstruction was either tumor, chronic pancreatitis, pancreatic abscess, pseudocyst, or stricture of the duct at the papilla of Vater. Two patients had Crohn's disease of the duodenum.     

Multiple stenting of refractory pancreatic duct strictures in severe chronic pancreatitis: long-term results

BACKGROUND AND STUDY AIMS: Dominant pancreatic duct strictures located in the head of the pancreas in patients with severe chronic pancreatitis are often managed by endoscopic placement of a single plastic stent. Patients with refractory strictures after prolonged stenting require repeated stent replacement or surgical pancreaticojejunostomy. Placement of multiple plastic stents has proved effective in managing postoperative biliary strictures. The aim of this study was to investigate the feasibility, efficacy, and long-term results of multiple stenting of refractory pancreatic strictures in severe chronic pancreatitis. PATIENTS AND METHODS: 19 patients with severe chronic pancreatitis (16 men, three women; mean age 45 years) and with a single pancreatic stent through a refractory dominant stricture in the pancreatic head underwent the following protocol: (i) removal of the single pancreatic stent; (ii) balloon dilation of the stricture; (iii) insertion of the maximum number of stents allowed by the stricture tightness and the pancreatic duct diameter; and (iv) removal of stents after 6 to 12 months. RESULTS: The median number of stents placed through the major or minor papilla was 3, with diameters ranging from 8.5 to 11.5 Fr and length from 4 to 7 cm. Only one patient (5.5 %) had persistent stricture after multiple stenting. During a mean follow-up of 38 months after removal, 84 % of patients were asymptomatic, and 10.5 % had symptomatic stricture recurrence. No major complications were recorded. CONCLUSION: Endoscopic multiple stenting of dominant pancreatic duct strictures in chronic pancreatitis is a feasible and safe technique. Multiple pancreatic stenting is promising in obtaining persistent stricture dilation on long-term follow-up in the setting of severe chronic pancreatitis.     

Endoscopic ultrasound-assisted rendezvous maneuver to achieve pancreatic duct drainage in obstructive chronic pancreatitis

Patients with mechanical obstruction of the pancreatic duct, which can be caused by chronic pancreatitis, suffer from recurrent attacks of pain and inflammation of the pancreas. We report a novel approach using an endoscopic ultrasound- (EUS-) assisted rendezvous technique, which allows drainage of the pancreatic duct in patients in whom primary management by transpapillary drainage during an endoscopic retrograde cholangiopancreatography (ERCP) procedure has failed. Transgastric puncture of the pancreatic duct was performed using a 19-gauge needle under EUS guidance, and a 0.035-inch guide wire was introduced into the duct and advanced through the papilla. This wire was pulled into the duodenum using a side-viewing duodenoscope. A papillotomy was performed using the standard technique and a plastic prosthesis was introduced. The patient tolerated the intervention well and was discharged with no further complaints. EUS-assisted drainage of the pancreatic duct using a rendezvous technique is an elegant and feasible minimally invasive endoscopic treatment for symptomatic patients with chronic pancreatitis, in whom transpapillary introduction of a catheter is not possible.     

Carcinoma of the pancreas presenting as acute pancreatitis: CT diagnosis

Three cases are reported in which acute pancreatitis was the presenting manifestation of an underlying carcinoma of the head of the pancreas. The rare association of acute pancreatitis and pancreatic carcinoma is reviewed and possible pathogenetic mechanisms are discussed. An underlying neoplasm should be suspected in a middle-aged or elderly patient presenting for the first time with acute pancreatitis for which no other cause is found. CT may suggest the correct diagnosis by identifying focal rather than diffuse pancreatic involvement, pancreatic duct dilatation, or lymphadenopathy.     

Treatment of pancreatic pseudocysts, pancreatic necrosis, and pancreatic duct leaks

Pancreatic pseudocysts arise as a complication of acute and chronic pancreatitis or pancreatic trauma (including postsurgical). Pancreatic necrosis occurs following severe pancreatitis and may evolve into an entity termed organized pancreatic necrosis that is endoscopically treatable. Pancreatic duct leaks are frequently seen in relation to pseudocysts and necrosis. Alternatively, pancreatic duct leaks may present with pleural effusions, ascites, or after pancreatic surgery or percutaneous drainage. Endoscopic treatment of pancreatic fluid collections and pancreatic duct leaks can be achieved using transpapillary and/or transmural stent placement.     

Clinico-morphological correlations of chronic pseudotumorous pancreatitis and cancer of the pancreas]

Examination of 57 pancreatic cancer patients and 40 subjects with chronic pseudotumorous pancreatitis revealed a resemblance in the clinical picture and uniform changes in the blood levels of pancreatic enzymes in both groups. Histological examination of 32 patients who expired from pancreatic cancer revealed total chronic pancreatitis manifested in inflammatory infiltration, focal destruction of the duct epithelium, atrophy, interstitial, periductular and perivascular sclerosis, dilatation of the ducts and pancreolithiasis. The character of the morphological changes in patients with pancreatic cancer corresponds to both primary and secondary origin of pancreatitis. Similarity of clinical manifestations and uniform changes in the blood content of pancreatic enzymes could be explained by the presence of chronic pancreatitis concurrent to pancreatic cancer.     

Laparoscopic pancreatic duct incision and stone removal and T-type tube drainage for pancreatic duct stone: A case report and review of literature

To study a more micro-invasive procedure for patients having pancreatic duct stones (PDS). Till now, there has been no report of laparoscopic pancreatic duct incision and stone removal and T-type tube drainage for PDS in the English literature. An 82-year-old man suffered from subxiphoid pain associated with a dilated pancreatic duct (7 mm) containing one stone, but without a mass in the head of the pancreas. Laparoscopic pancreatic duct incision, stone removal, and T-type tube drainage were successfully performed without intraoperative or postoperative complications. An uneventful operation was performed with laparoscopically completed procedures in 160 min. The intraoperative loss of blood was around 50 mL. After patient a discharge on day 11, complete relief from the subxiphoid pain was reported at a follow-up visit 15 mo later. Laparoscopic pancreatic duct incision with stone removal and T-type tube drainage is applicable in carefully selected patients and can be effectively and safely used for the treatment of the abdominal pain of chronic pancreatitis.     

Chronic calcific pancreatitis with pancreatic duct lithiasis due to stenosing papillitis

We have described a case of chronic pancreatitis due to stenosing papillitis relieved by sphincteroplasty and removal of pancreatic duct stones, as opposed to a major pancreatic resection.     

表观弥散系数值的离散系数在胰腺癌及肿块型胰腺炎鉴别诊断中的应用

目的：探讨表观弥散系数（ADC）值的离散系数对于胰腺癌及肿块型胰腺炎鉴别诊断的应用价值.方法：收集胰腺癌患者28例,肿块型胰腺炎患者7例,行磁共振弥散加权成像（DWI）检查,分别测量每一病灶ADC值的均值（x）及标准差（s）,并计算每一个病灶ADC值的离散系数（CV,CV=s/x）.采用Student＇st检验对两组患者病灶ADC值均值及CV进行比较.结果：胰腺癌组ADC值均值为1.46±0.29,肿块型胰腺炎组ADC值均值为1.58±0.28,经Student＇s t检验显示两组间无显著差异（t=1.02,P=0.32）;胰腺癌组ADC值CV为0.16±0.06,肿块型胰腺炎组CV为0.10 ±0.04,两组CV之间具有显著差异（t=2.44,P=0.02）.结论：胰腺DWI检查中,ADC值CV较ADC值均值对于胰腺癌与肿块型胰腺炎的鉴别诊断具有更高价值.     

焦磷酸测序法快速检测胰腺癌K-ras基因点突变

目的 建立基于焦磷酸测序技术的胰腺癌K-ras基因点突变的检测方法,并与Sanger测序法作一比较.方法 用焦磷酸测序法(Pyrosequencing)和Sanger测序法(Sanger sequencing)分别在10名正常胰腺组织、49例胰腺癌、11例慢性胰腺炎、18例胰腺良性囊肿、7例胰岛素癌、9例壶腹癌、7例胆管癌及7例十二指肠乳头癌石蜡包埋组织的DNA中检测K-rag基因12密码子点突变.结果 采用上述两种方法在所有正常胰腺组织、慢性胰腺炎、胰腺良性囊肿、胰岛素癌、壶腹癌、胆管癌及十二指肠乳头癌均未见K-ras基因点突变,而采用焦磷酸测序法发现胰腺癌石蜡包埋组织K-ras基因点突变率为71.4%(35/49),显著高于采用Sanger测序法发现胰腺癌石蜡包埋组织K-rag基因点突变率(61.2%,30/49).结论 焦磷酸测序法较Sanger测序法更为敏感,且焦磷酸测序法准确、快速、高通量,适合临床标本的批量测定.     

Disintegration of a pancreatic duct stone with extracorporeal shock waves in a patient with chronic pancreatitis

We report the case of a 33-year-old woman with chronic calcifying pancreatitis in whom an intraductal pancreatic stone with a diameter of 8 mm was successfully disintegrated with extracorporeal shock waves, permitting subsequent endoscopic extraction of the fragments. The patient had a mild attack of pancreatitis after the treatment. We conclude that shockwave lithotripsy of a pancreatic duct stone in patients with chronic pancreatitis is possible. It should, however, be viewed with reservation until further experience has been gained.