Chronic obstructive pancreatitis due to tiny (0.6 to 8 mm) benign tumors obstructing pancreatic ducts: report of three cases

Three cases of obstructive pancreatitis are described in nonalcoholic women aged 56 to 58 years with a 2-month to 5-year history of recurrent attacks of pancreatic pain associated with intermittent raised serum pancreatic enzymes. The diagnosis was made by sonography showing an enlarged hyperechogenic tail of the pancreas, with a dilated duct, the rest of the pancreas being normal, and by ERCP showing a partial stenosis of the main pancreatic duct with regular dilatation of collateral branches distally to it. Surgical resection of the pancreatic tail cured all three patients. In the obstructed part of the pancreas, the lesions are typical of obstructive pancreatitis with perilobular and sometimes intralobular fibrosis of the same degree in the different lobules of the diseased area and not patchy as in chronic calcifying pancreatitis. The changes in collateral ducts are not marked, and there is an absence of intraductal plugs. Fat necrosis and pseudocysts may be found. Tumors responsible for the obstruction were the smallest islet cell tumors (0.6 and 8 mm) and serous cystadenoma (5 mm) responsible for symptoms ever published. Cephalad to the stricture, the pancreas was normal. When the etiology of chronic pancreatitis is atypical, especially when it occurs in nonalcoholic women aged greater than 50 years, a careful sonography (or computed tomographic scan) and ERCP must be done. Serial sections of the resected pancreas at the level of the obstruction and distal to it are often necessary to demonstrate the tumor.     

10955例经内镜逆行胰胆管造影术患者临床总结分析

目的探讨经内镜逆行胰胆管造影术（ERCP）对胆胰疾病的诊疗价值。方法回顾性分析1995年1月至2013年7月间完成ERCP诊治的患者10955例,其中男6186例,女4769例,平均年龄（65．57±14．44）岁。总结并分析ERCP诊治病种、发病年龄、年度数量、麻醉方式及插管成功率等指标。结果10955例患者中,诊断性ERCP167例,治疗性ERCP10788例。2002年至2012年ERCP手术例数年平均增长率是19．58％。首次ERCP胆管插管成功率是97．23％,总ERCP胆管插管成功率是99．59％。常见的ERCP诊治疾病包括肝外胆管结石（40．85％）、肝门部胆管癌（10．53％）、化脓性胆管炎（10．44％）、胰头癌（10．04％）、慢性胰腺炎（8．24％）、肝外胆管癌（7．68％）、壶腹周围癌（6．96％）、胆源性胰腺炎（3．94％）、良性乳头狭窄（3．88％）、乳头癌（3．50％）。肝外胆管结石、化脓性胆管炎、良性乳头狭窄高发年龄是40～50岁,慢性胰腺炎高发年龄是50—60岁,胆源性胰腺炎、肝门部胆管癌、肝外胆管癌、胰头癌、壶腹周围癌、乳头癌的高发年龄是70—80岁。2011年至2013年中,98．74％患者行全凭静脉麻醉ERCP。结论ERCP已经成为胆胰疾病诊治的重要手段,适合于肝外胆管结石、化脓性胆管炎、恶性胆管梗阻等疾病,尤其是高龄患者的诊治。全凭静脉麻醉ERCP是安全、有效的。     

A Case of Groove Pancreatitis with Duodenal Stenosis

A 58‐year‐old man presented with a 2‐month history of nausea and vomiting. Blood levels of hepatic enzymes and pancreatitis markers were slightly elevated. Hypotonic duodenographic and endoscopic examinations revealed stenosis encircling the descending duodenum. A computed tomography (CT) scan showed inflammatory changes in the head of the pancreas and thickening of the duodenal wall. Magnetic resonance cholangiography demonstrated stenosis of the intrapancreatic segment of the common bile duct and diffuse dilatation of the main pancreatic duct, without irregularity. At laparotomy, microscopic examination of a needle biopsy specimen of the head of pancreas revealed no evidence of malignancy. Distal gastrectomy with Billroth II anastomosis was performed. Microscopically, fibrous thickening of the duodenal wall, serositis and hyperplasia of Brunner's glands were found. The presence of duodenal stenosis due to segmental pancreatitis, referred to as groove pancreatitis, was confirmed. The elevated blood levels of pancreatitis markers returned to the normal range 8 months after the operation. Ultrasonic echography and abdominal CT also revealed a marked reduction in dilatation of the extrahepatic bile duct and the main pancreatic duct. In patients suspected of having pancreatic carcinoma or regional pancreatitis, groove pancreatitis should be included in the differential diagnosis.     

Endoscopic pancreatography in chronic pancreatitis of the tropics

The ERCP findings in 13 patients with chronic pancreatitis of the tropics are reported. 7 of the patients had pancreatic calculi on plain film of abdomen and 6 had no calcification. The changes observed in the pancreatograms were tortuosity, dilatation, stenosis, obstruction, cyst formation and presence of calculi in the main pancreatic ducts and their finer branches. The calcific variety showed a greater degree of ductal derangement compared to the non-calcific variety. The common bile duct was normal in all the patients. The pancreatographic changes observed are similar to those described in the alcoholic and other varieties of chronic pancreatitis.     

MRCP and MRI findings in 9 patients with autoimmune pancreatitis

AIM: To evaluate magnetic resonance cholangiopancre-atography (MRCP) findings in conjunction with magnetic resonance (MR) images in autoimmune pancreatitis (AIP) patients. METHODS: Nine patients with AIP underwent MRI, MRCP, endoscopic retrograde cholangiopancreatography (ERCP), computed tomography, and ultrasonography. The MRCP and MR images taken before and after steroid therapy were reviewed and compared with other imaging modalities. The MRCP findings of the AIP cases were compared to those of 10 cases with carcinoma of the head of the pancreas. RESULTS: On MRCP, the narrowed portion of the main pancreatic duct noted on ERCP was not visualized, while the non-involved segments of the main pancreatic duct were visualized. The degree of upstream dilatation of the proximal main pancreatic duct was milder than that seen in cases of pancreatic carcinoma. Stenosis or obstruction of the lower bile duct was detected in 8 patients. MR images showed enlargement of the pancreas with decreased signal intensity on T1-weighted MR images, increased signal intensity on T2-weighted MR images, and, in 3 patients, a hypointense capsule-like rim. After steroid therapy, the previously not visualized portion of the main pancreatic duct was seen, along with improvement of the bile duct stenosis. Pancreatic enlargement decreased, and the abnormal signal intensity on both T1- and T2-weighted MR images became isointense. CONCLUSION: MRCP cannot differentiate irregular narrowing of the main pancreatic duct seen with AIP from stenosis of the main pancreatic duct seen with pancreatic carcinoma. However, MRCP findings in conjunction with MR imaging of pancreatic enlargement that shows abnormal signal intensity on T1- and T2-weighted MR images are useful in supporting a diagnosis of AIP.     

Chronic Pancreatitis and the Hepatobiliary System

Alcohol-induced chronic pancreatitis involving the head of pancreas may have profound effects on the hepatobiliary system. The natural history, complications, and management of the syndrome are presented, using selected cases to emphasize important features. Chronic pancreatitis can cause mechanical obstruction to both the distal common bile duct and the proximal pancreatic duct. In the common bile duct this will result in proximal dilatation above the stenosis with bile stasis. Possible sequelae are ascending cholangitis, cholecystitis, biliary calculi formation, and secondary biliary cirrhosis. The mechanical effects of stricture of the proximal pancreatic duct may exacerbate pancreatic dysfunction. The clinicopathological spectrum of chronic pancreatitis with biliary obstruction encompasses three clinical types–"transient,""recurrent." and "persistent." The widespread effects of the syndrome are evident from the involvement of pancreas, proximal pancreatic duct, papilla of Vater, liver, peripheral biliary tree, common bile duct, gallbladder, and reticuloendothelial system. Essential to management is surgery which should be considered when there is objective evidence of obstruction to the common bile duct. Choledochoduodenostomy is the preferred type of operation. If dilatation is mild and jaundice transient, conservative therapy with careful observation is advocated.     

Inferior head resection of the pancreas and cyst resection for choledochal cyst with chronic calcifying pancreatitis

We report inferior head resection of the pancreas and cyst resection for congenital choledochal cyst with an anomalous arrangement of pancreaticobiliary duct and chronic calcifying pancreatitis. A 42-year-old man was admitted to the National Cancer Center Hospital East complaining of back pain. Contrast-enhanced computed tomography showed marked dilatation of the bile duct and multiple pancreatic stones in the main pancreatic duct. Endoscopic retrograde cholangiopancreatography demonstrated pancreatic stones in the dilated main pancreatic duct. The patient underwent cyst excision, inferior head resection of the pancreas, hepaticojejunostomy and lateral pancreaticojejunostomy. The postoperative course was uneventful. This procedure relieved the back pain. Choledochal cyst with anomalous arrangement of the pancreaticobiliary duct is frequently associated with acute pancreatitis. Inferior head resection of the pancreas removed the common channel which could be the cause of relapsing pancreatitis. Thus, inferior head resection can play a role in the management of choledochal cyst with chronic pancreatitis.     

The double duct sign in patients with malignant and benign pancreatic lesions

BACKGROUND: The double duct sign, a simultaneous stenosis of the common bile duct and the pancreatic duct by endoscopic retrograde cholangiopancreatography (ERCP), has been reported to predict the presence of pancreatic cancer with a high degree of certainty. METHODS: To test the specificity of the double duct sign for pancreatic cancer in patients with malignant and benign pancreatic lesions, we have reviewed all ERCP films obtained during a 24-month period (n = 1209) and corresponding clinical follow-up data obtained during a period of 4 years. RESULTS: Forty-three patients were identified as having a double duct stenosis on ERCP, 15% of whom did not have pancreatic carcinoma. In 4 patients chronic pancreatitis was confirmed by serial histologic sections of the surgical specimen. Data on the lengths of the stenotic segment in either the pancreatic duct or the bile duct did not contribute to a better discrimination between benign and malignant disease. CONCLUSION: The specificity of the double duct sign in predicting the presence of pancreatic cancer appears to be lower than previously reported. Better discrimination between malignant and benign disease of the pancreas will be difficult to achieve with existing imaging techniques.     

Ultrasound secretin test in patients with pancreas divisum--an aid in the diagnosis of papillary or dorsal duct stenosis?

BACKGROUND: Pancreas divisum is a common anatomical variant of pancreatic ductal anatomy. Obstruction of the accessory papilla could cause pain and pancreatitis. It has been suggested that accessory papillary sphincter obstruction can be assessed by sonographic measurement of pancreatic duct diameter after secretin stimulation. METHODS: We now compared our results of sonographic pancreatic duct diameter measurements before and during 10 min after intravenous injection of 1 CU secretin per kg body weight in 32 patients with confirmed pancreas divisum and 20 healthy volunteers. RESULTS: The healthy controls showed a short-lasting duct caliber enlargement by about 93% of the basal diameter within 5 min after secretin injection. 25 pancreas divisum patients without pancreatic disease had a secretin-induced duct dilatation by about only 58%. In four patients with pancreas divisum and chronic pancreatitis no or just a slight duct dilatation was observed after stimulation. Two patients with dorsal duct stenosis as well as one patient with accessory papilla stenosis, however, showed a marked and prolonged secretin-induced duct enlargement by about 155% of the basal duct diameter. CONCLUSION: In this investigation pancreatic duct response to secretin stimulation in pancreas divisum patients without pancreatic disease was less marked than in normal individuals. Thus, a particularly distinct and long-lasting duct dilatation could support the suspicion of accessory papilla or pancreatic duct stenosis.     

Surgical treatment of chronic pancreatitis with pancreatic main duct dilatation: long term results after head resection and duct drainage

Tissue and duct hypertension is considered as a major factor in the etiology of pain in patients with chronic pancreatitis (CP). Duct dilatation is a consequence of duct obstruction due to scars or duct stones. Nevertheless, the procedure of choice, drainage or resection, is still under discussion. We present long-term results of patients operated with duodenum-preserving pancreatic head resection (DPPHR) combined with a Partington-Rochelle duct drainage in cases of chronic pancreatitis with multiple stenosis and dilatation of the side ducts.Methods and patients. From April 1982 to September 2001, in 55 out of 538 patients with chronic pancreatitis, a DPPHR with additionally Partington-Rochelle duct drainage was performed (44 male, 11 female, mean age 45.8 years). Ninety-two percent of the patients suffered from alcoholic pancreatitis. Medical respective pain treatment for chronic pancreatitis was in median 64.5 months prior to surgery. The indications for surgery were in 87% pain, 59% of the patients had an inflammatory mass in the head of the pancreas, 36% a common bile duct stenosis and 5% a severe stenosis of the duodenum. The endocrine function (OGGT) was impaired in 79% of the patients preoperatively.Results. Hospital mortality was 0%, postoperative complications occurred in 11 patients. Follow-up: All except 2 patients were followed up in the outpatient clinic with the mean follow-up time of 69.7 months (8–105 months), the late mortality was 9%. Sixty-eight percent of the patients were completely free of pain, 29% had occasional pain, 3% suffered from a further attack of pancreatitis. Body weight increased in 79%, 58% were professionally rehabilitated. Late postoperative endocrine function was unchanged in 85% (improved in 5%, deteriorated in 10%).Conclusion. The pain control in patients with multiple duct stenosis after duodenum-preserving pancreatic head resection with duct drainage leads to long-standing absence of pain and low recurrence rate of attacks of pancreatitis.     

Annular pancreas associated with pancreatolithiasis: a case report

We present a case of annular pancreas associated with pancreatolithiasis. A 41 year-old Japanese man with epigastric pain was admitted to the surgical service at Miyazaki Medical College Hospital. Contrast duodenography revealed severe stenosis of the descending duodenum. Cholangiography showed a stenotic segment of the intrapancreatic common bile duct surrounded by calcifications. Computed tomography of the abdomen revealed calcifications in the posterior region of the pancreatic head. Percutaneous cannulation of the pancreatic ductal system, using ultrasonic guidance, demonstrated a slightly dilated pancreatic duct in the body, stenosis of the duct of Wirsung in the pancreatic head, a normal duct of Santorini, and calcifications in the duct of an annular pancreas which communicated with the duct of Wirsung. At surgery, the second portion of the duodenum was completely encircled by the annular pancreas, and a Whipple procedure was performed. Including this patient, 170 adult cases of annular pancreas have been reported in Japan since 1922. Surgery was performed on 122 patients; 106 of these procedures were well documented. A Whipple procedure was performed on 16 patients, including the present case. Nine of these 16 patients had associated malignant disease, while the others had benign pancreatic disease. This is the fifth reported case of pancreatolithiasis associated with an annular pancreas in Japan. This case emphasizes that an annular pancreas may predispose to localized chronic pancreatitis and pancreatolithiasis.     

丝留置切割法在慢性胰腺炎胰管困难性 插管中的价值初探

目的 评价导丝留置切割法对困难性胰管狭窄再扩张的安全性及有效性。方法 收集2017年11月—2019年4月期间在南京鼓楼医院消化内科行经内镜逆行胰胆管造影术(endoscopic retrograde cholangiopancreatography, ERCP) 胰管支架置入失败,狭窄胰管仅能允许导丝通过并留置导丝的慢性胰腺炎患者资料,探讨导丝留置切割对于困难性胰管狭窄的扩张作用,分析导丝留置时间、再次ERCP胰管支架置入成功率、术后淀粉酶水平、导丝留置近期并发症及随访结果。结果 共计5例患者ERCP术中胰管狭窄扩张失败后留置导丝,平均留置导丝2.4 d后,再次行ERCP,胰管狭窄部位均可成功扩张,并置入胰管支架。并发症发生方面,仅有1例患者首次ERCP术后发生急性胰腺炎,经过对症治疗好转。结论 导丝留置切割是一种简单、安全、有效的胰管狭窄扩张新方法,对处理慢性胰腺炎胰管困难性插管具有重要的临床价值。     

Idiopathic fibrosing pancreatitis associated with ulcerative colitis

Idiopathic fibrosing pancreatitis has been associated with Sjögren''s syndrome, primary biliary cirrhosis and primary sclerosing cholangitis. This condition frequently develops in childhood and youth, and has also been related to ulcerative colitis and pericholangitis. Pancreatic complications have been rarely described as systemic complications of ulcerative colitis. A 25-year-old man presented with epigastric pain and jaundice. Abdominal ultrasonography, computed tomography (CT), magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) revealed a diffuse enlargement of the pancreas, filiform distal stenosis of the common bile duct and intrahepatic bile ducts, and pancreatic duct dilatation. At operation, a rock-hard and nodular pancreas was noted. Cholecystectomy and Roux-en-Y hepaticojejunostomy, with an access loop, was successfully performed. Idiopathic fibrosing pancreatitis should be considered in young patients with obstructive jaundice, especially those affected with chronic inflammatory or autoimmune diseases. Glucocorticoid therapy would be the first-line treatment, although many patients require operation.     

ERCP在不明原因肝外阻塞性黄疸的临床应用

目的探讨内镜逆行胰胆管造影（ERCP）在经常规检查不明原因肝外阻塞性黄疸的临床应用价值。方法收集经B超、cT和,或MRCP检查诊断不明原因胆胰疾病或肝外胆管梗阻病人45例,男28例,女17例,年龄21—80岁,均行ERCP术。结果45例病人行ERCP术,其中42例诊断为胆道微结石（Biliary microlithiasis,BML）,42例均行乳头扩张术／EST4-胆道取石术;3例为胆总管下端炎性狭窄而行胆道内支架植入术;1例ERCP取石术后并发轻症胰腺炎,经内科保守治疗后痊愈,l例因腹痛再发行胆囊切除术,其余患者经ERCP治疗后腹痛、黄疸均缓解。结论BML是不明原因肝外阻塞性黄疸的主要原因,ERCP是不明原因肝外阻塞性黄疸安全、有效的诊断及治疗手段。     

胰腺分裂内镜治疗价值

目的探讨内镜下治疗胰腺分裂的疗效和安全性。方法收集2006年6月至2013年6月在南京大学医学院附属鼓楼医院消化科就诊的8例胰腺分裂患者的临床资料,对术中及术后情况进行回顾性分析。结果8例胰腺分裂患者共行经内镜逆行胰胆管造影术28例次,均置入胰管支架,其中7例同时行副乳头括约肌切开术,6例行内镜下扩张术,1例行胰管取石术。术后出现1例次轻度胰腺炎。随访2～47个月,1例死于胰腺癌,3例已拔出支架,3例定期复查,1例失访。患者术后慢性胰腺炎急性发作频率及腹痛程度均较术前明显降低。结论内镜下治疗胰腺分裂安全有效,可减少胰腺炎发作频率,减轻术后腹痛程度,术后并发症发生率低。     

Laparoscopic Pancreatic Biopsy in Autoimmune Pancreatitis—Report of TWO Cases

Two cases of autoimmune pancreatitis that were diagnosed by laparoscopic pancreatic biopsy are reported. Patient 1 was a 71–year-old woman with obstructive jaundice and dry eyes. Endoscopic retrograde cholangiopancreatography (ERCP) revealed stenosis of the distal common bile duct and proximal main pancreatic duct. Only the head of the pancreas was enlarged. The patient had associated Sjogren's syndrome and sclerosing cholangitis. Patient 2 was a 65–year-old man with obstructive jaundice that occurred after laparoscopic cholecystectomy. ERCP revealed a diffusely irregular and narrowed pancreatic duct and stenosis of the distal common bile duct. The whole pancreas was enlarged. Both patients underwent laparoscopic pancreatic biopsy to rule out pancreatic cancer. The definitive diagnosis in each case was autoimmune pancreatitis. The postoperative course in both cases was uneventful. Both patients recovered quickly with steroid therapy undertaken soon after the biopsy. In summary, a laparoscopic approach for the pancreatic biopsy in autoimmune pancreatitis appears to be feasible and useful in determining the therapeutic strategy. (Dig Endosc 1999; 11: 250–254)     

Clinicopathologic study on chronic pancreatitis with diffuse irregular narrowing of the main pancreatic duct]

We studied the clinicopathologic features of 13 cases of chronic pancreatitis with diffuse irregular narrowing of the main pancreatic duct (MPD). It occurs frequently in relatively elder men. Diffuse irregular narrowing of the MPD and stenosis of the common bile duct on ERCP, and swelling of the pancreas on US/CT were detected in all cases. An autoimmune mechanism might be involved in the etiology at least in 5 patients with hypergammaglobulinemia and positive autoantibodies. Surgical therapy was performed in 8 patients and 3 patients were treated with steroids. No patients showed recurrence of pancreatitis. Histologic findings were characterized by diffuse lymphoplasmacytic infiltration with marked interstitial fibrosis in the pancreas, obliterated phlebitis of the pancreatic veins. Similar inflammatory process involved the bile duct and the gallbladder. These histologic findings were similar to those of multifocal fibrosclerosis. Chronic pancreatitis with diffuse irregular narrowing of the MPD is overlapped with autoimmune pancreatitis in many cases, but may be a variant of multifocal fibrosclerosis involving the pancreas in some cases.     

Intraductal carcinoma in a surgically resected pancreas with chronic pancreatitis

A 59-yr-old Japanese male presented with epigastralgia. Endoscopic retrograde cholangiopancreatography (ERCP) revealed narrowing of the inferior common bile duct and protein plugs in the main pancreatic duct. He was diagnosed as suffering from chronic pancreatitis with suspicion of a pancreatic head tumor, and a pancreatoduodenectomy was performed. Histologically, a diffuse chronic pancreatitis was evident in the resected pancreas. Although no tumors were seen in the head portion of the pancreas around the inferior common bile duct, an intraductal carcinoma was found in the second branch of Santorini’s duct. Precancerous alteration of the duct epithelium, presenting papillary hyperplasia, and atypical hyperplasia were observed in areas continuous with the intraductal carcinoma. Immunohistochemically, carcinoembronic antigen (CEA) was specifically expressed in atypical hyperplasia and intraductal carcinoma, but not in papillary hyperplasia.     

Perforation of a pancreatic pseudocyst induced by abdominal sonography

A fifty-year-old man complained of abdominal pain, nausea, loss of appetite, postprandial vomiting and loss of weight. Abdominal sonography revealed a chronic calcifying pancreatitis with a tubular stenosis of the common bile duct, dilatation of the pancreatic duct and multiple pancreatic duct stones. Distal of the pylorus there was an intramural pseudocyst, which had led to the obstruction of the duodenal lumen. Shortly after the ultrasound examination abdominal pain increased. In addition, an elevation of serum lipase levels was noted, but reclined rapidly the next day and was normalized a few days later. The patient was well the next morning, the symptoms of gastric retention disappeared and he had a good appetite. A CT of the abdomen two days later showed the chronic pancreatitis but could not confirm the pseudocyst and a subsequent repeat sonography revealed only a remnant of the pseudocyst. In conclusion it can be assumed that the intramural pseudocyst ruptured when pressure was applied with the ultrasound transducer to displace interfering colonic gas. Although it cannot be advised as a treatment measure for a pseudocyst, regression of a pseudocyst due to emptying into the gastrointestinal tract has to be expected.     

Value of ultrasound and liver function tests in determining the need for endoscopic retrograde cholangiopancreatography in unexplained abdominal pain.

The value of serum liver function tests and abdominal ultrasound as screening tests of the need for endoscopic retrograde cholangiopancreatography (ERCP) was determined in patients with unexplained abdominal pain without associated jaundice. In 1989 and 1990 1005 ERCPs were undertaken, of which 138 (14%) were for this indication. The duct or ducts of interest were delineated by ERCP in 95% of patients. The lesions found were bile duct stones in 10 patients, chronic pancreatitis in five, pancreatic carcinoma in one, peptic ulcer or duodenitis in four. A satisfactory ultrasound examination had been performed in 94% of patients. For chronic pancreatitis, its sensitivity was 60% and specificity 95%. For choledocholithiasis, the ultrasonic detection of duct dilatation or stones had a sensitivity of 90% and specificity of 86%. Of the liver function tests, the alkaline phosphatase was more sensitive (67%) than the transaminases (44%) in indicating the presence of bile duct stones and had a high specificity (95%). None of the 10 patients with duct stones had normal ultrasound and normal alkaline phosphatase. Thus it was found that demonstration of a normal common bile duct by abdominal ultrasound and normal serum alkaline phosphatase together have 100% specificity in excluding bile duct stones. Using such knowledge over the two year period of this study would have spared 36 patients the need for ERCP.