Air in the main pancreatic duct associated with a pancreatic intraductal papillary mucinous neoplasm

A 62-year-old man was referred to our hospital after ultrasonographic mass screening detected a pancreatic cyst that proved to be an intraductal papillary mucinous neoplasm. Computed tomography additionally demonstrated air in the main pancreatic duct. Magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography delineated a filling defect in the main pancreatic duct in the body of the pancreas. The sphincter of Oddi was open. The main pancreatic duct was dilated by viscous mucin; air in the duct was attributed to consequent dysfunction of the sphincter. Laboratory findings included no significant abnormality. The patient has remained asymptomatic during follow-up. Of 25 previously reported cases with air in the duct, only 1 involved an intraductal papillary mucinous neoplasm.     

Primary hydatid cyst of the pancreas related to main pancreatic duct. A case report

A case of primary hydatid cyst of the pancreas related to the main pancreatic duct is presented. Abdominal ultrasound and computed tomography revealed a cyst at the tail of the pancreas. Endoscopic retrograde cholangiopancreatography showed dilatation of the distal part of the pancreatic duct related to the cystic cavity. While the diagnosis of the pancreatic pseudocyst was established preoperatively, the hydatid cyst was demonstrated at laparotomy and then the final decision of cystogastrostomy was employed. Following the uneventful postoperative period, the patient was discharged on the 8th postoperative day.     

Mucinous cystadenoma of the pancreas 17 years after excision of gallbladder because of a choledochal cyst

A 56-year-old woman who had undergone excision of the gallbladder because of a choledochal cyst had a tumorous lesion of the pancreas identified by upper abdominal ultrasonography, but an operation was not carried out, because there was no apparent increase in the cystic mass and no elevation of serum tumor markers. In October 2001, she was admitted to our hospital to check for malignancy because of elevated levels of the tumor marker Dupan-2. Abdominal enhanced computed tomography and upper abdominal ultrasonography revealed a large multilocular cystic mass in the body to tail of the pancreas. Endoscopic retrograde cholangiopancreatography showed elongation of the common duct that communicates with the common bile duct and the main pancreatic duct, indicating an anomalous arrangement of the biliary and pancreatic duct system. No apparent communications between the cystic mass and the main pancreatic duct were observed. In January 2002, the patient underwent a spleen-preserving distal pancreatectomy, and histopathological and immunohistochemical examinations led to the diagnosis of pancreatic mucinous cystadenoma with ovarian-like stroma. The mucinous cystadenoma was detected 17 years after the operation for the choledochal cyst. To the best of our knowledge, no documented case reports of mucinous cystadenoma of the pancreas associated with a choledocal cyst have been reported to date. We present here the first case report of pancreatic mucinous cystadenoma occurring in the body to tail of the pancreas, associated with a choledocal cyst.     

Serous cystadenoma of the pancreas communicating with a pancreatic duct

Summary Conclusion To differentiate serous cystadenoma from other cystic lesions communicating with the pancreatic duct, careful radiological examination is necessary. Background Communication between the cystic cavity and the pancreatic duct in an ordinary serous cystadenoma is uncommon, although it is not uncommon in other cystic lesions, such as pseudocyst, mucinous cystadenoma/adenocarcinoma, and intraductal papillary tumor. Methods A serous cystadenoma of the pancreas communicating with main pancreatic duct in a 76-yr-old male is reported. Results The communication was preoperatively demonstrated by endoscopic retrograde cholangiopancreatography and confirmed by histopathological examination of the resected specimen.     

A case of concurrent pancreatic intraepithelial neoplasia and type 1 autoimmune pancreatitis with marked pancreatic duct dilatation

The case patient was a previously healthy 82-year-old male. Abdominal ultrasound during a medical check-up revealed a dilatation of the main pancreatic duct, and the patient was referred to our hospital for closer examination. Contrast-enhanced computed tomography (CT) revealed a low-density mass of 20 mm in the pancreatic head–body transitional area. Magnetic resonance cholangiopancreatography (MRCP) revealed marked dilatation of the main pancreatic duct and branches in the body–tail. On endoscopic ultrasonography (EUS), a hypoechoic mass with irregular shape was detected, which was consistent with the area of pancreatic duct stenosis. Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) and pancreatic juice cytology were performed; however, there were no malignant findings. Serum IgG4 levels had increased to 299 mg/dL. Cancer of the pancreatic head was suspected and a pancreaticoduodenectomy was thus performed. Macroscopic findings included a white mass with indistinct border in the constricted part of the pancreatic duct and mottled fatty replacement of the pancreatic head. Pathologically, a large amount of IgG4-positive plasma cells was found in the white mass, with storiform fibrosis and obstructive phlebitis, which led to the diagnosis of type 1 autoimmune pancreatitis (AIP). Furthermore, scattered low–high grade pancreatic intraepithelial neoplasia lesions were observed throughout the pancreatic head, separately from the AIP lesion. This is an interesting case that suggests an association between AIP and pancreatic cancer. We report the case with a review of relevant literature.     

Cystic duct directly joining the main pancreatic duct

A unique anomaly of the direct union between the cystic duct and the main pancreatic duct is presented. A 19-year-old man with a history of repeated epigastralgia underwent endoscopic retrograde cholangiopancreaticography that showed a direct union between the cystic duct and the main pancreatic duct. No pancreaticobiliary maljunction was noticed. Cholecystectomy accompanied by resection of the long cystic duct was performed. The excised gallbladder showed cholesterolosis, chronic cholecystitis, and hyperplasia of the pseudopyloric glands microscopically. The patient has been well for 3 years since surgery.     

New cannulation method for pancreatic duct cannulation-bile duct guidewire-indwelling method

The patient was a 58-year-old male with symptomatic alcoholic chronic pancreatitis.Since a 10 mm calculus was observed in the pancreatic body and abdominal pain occurred due to congestion of pancreatic juice,endoscopic retrograde cholangiopancreatography was conducted for assessment of the pancreatic duct and treatment of pancreatic calculus.Pancreatogram was slightly and insuff iciently obtained by injecting the contrast media via the common channel of the duodenal main papilla.We tried to cannulate selectively into the pancreatic duct for a clear image.However,the selective cannulation of the pancreatic duct was difficult because of instability of the papilla.On the other hand,selective cannulation of the bile duct was relatively easily achieved.Therefore,after the imaging of the bile duct,a guidewire was retained in the bile duct to immobilize the duodenal papilla and cannulation of the pancreatic duct was attempted.As a result,selective pancreatic duct cannulation became possible.It is considered that the bile duct guidewire-indwelling method may serve as one of the useful techniques for cases whose selective pancreatic duct cannulation is diff icult("selective pancreatic duct diff icult cannulation case").     

A giant retention cyst of the pancreas (cystic dilatation of dorsal pancreatic duct) associated with pancreas divisum

We describe a rare case of pancreas divisum associated with a giant retention cyst (cystic dilatation of the dorsal pancreatic duct), presumably formed following obstruction of the minor papilla. The patient was treated by pancreatico(cysto)jejunostomy. A 50-year-old man was admitted with complaints of increasing upper abdominal distension and body weight loss. There was no previous history of pancreatitis, gallstones, drinking, or abdominal injury. An elastic-hard tumor-like resistance was palpable in the upper abdomen. Computed tomography and ultrasound (US) examinations revealed a giant cystic lesion expanding from the pancreas head to the tail. Endoscopic retrograde cholangiopancreatography findings showed a looping pancreatic duct which drained only the head and uncinate process of the pancreas to the main papilla. A US-guided puncture to the cystic lesion revealed that the lesion continued to the main pancreatic duct in the tail of pancreas. The lesion was connected to a small cystic lesion, which was located inside the minor papilla, and ended there. The amylase level in liquid aspirated from the cyst was 37 869 IU/l, and the result of cytological examination of the liquid showed class II. A pancreatico(cysto)jejunostomy was performed, with the diagnosis being pancreas divisum associated with a retention cyst following obstruction of the minor papilla. The histological findings of a specimen from the cyst wall revealed that the wall was a pancreatic duct covered with mildly inflammatory duct epithelium; there was no evidence of neoplasm. The patient is currently well, and a CT examination 2 years after the operation showed disappearance of the cyst and normal appearance of the whole pancreas. Received: April 24, 2001 / Accepted: September 14, 2001     

Endoscopically placed pancreatic stent in a patient with concomitant two locations of main pancreatic duct disruption following pancreatic trauma

Severe pancreatic trauma involving disruption of the main pancreatic duct usually requires operative management. Recently, the successful non-operative treatment of proximal main pancreatic duct injuries by pancreatic stent has been described as having good results. Computed tomography of a 36-year-old man who sustained a blunt abdominal trauma in a motor vehicle accident disclosed a large amount of fluid in the cavity of the lesser sac, as well as a laceration of the pancreatic parenchyma at the pancreatic neck. Without definite evidence of pancreatic duct injury during laparotomy, no pancreatic resection was performed. However, postoperative endoscopic retrograde cholangiopancreatography showed 2 sites of main pancreatic duct disruption at the pancreatic neck and body, respectively. The first attempt for endoscopic pancreatic drainage failed with the endoscopic nasopancreatic drainage tube penetrating into the peritoneal cavity through the distal disruption site. A 5-French pancreatic stent was used for another attempt and successfully passed through the proximal disruption site with its tip located just proximal to distal disruption site. The patient improved steadily and was discharged uneventfully. The presenting case demonstrated that the endoscopically placed pancreatic stent was highly effective for the management of severe pancreatic trauma even though there were 2 sites of main pancreatic duct disruption, and pancreatic resection could be avoided.     

A case report of pancreatic serous cystadenoma coexistent with adenosquamous carcinoma

A 70-year-old man was admitted to our hospital because a mass was incidentally found in the body of the pancreas. The mass was suspected to be serous cystadenoma from the findings of abdominal enhanced computed tomography, magnetic resonance imaging and endoscopic ultrasonography. In addition, another solid mass was detected in the pancreatic head on imaging tests. Magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography showed stenosis both of the main pancreatic duct at the head and bile duct, but the brushing cytology of the bile duct at ERCP showed no malignant cells. However, the findings of several examinations strongly suggested the coexistence of a serous cystadenoma and a pancreatic cancer, therefore we conducted spleen-preserving total pancreatectomy, and the pathological findings of the resected specimen showed serous cystadenoma coexistence with pancreatic adenosquamous carcinoma.     

A case of gallbladder adenomyomatosis with pancreaticobiliary maljunction and an anomaly of the cystic duct joined the common channel

A 46-yr-old woman was admitted to our hospital with mild epigastric pain. Ultrasonography and computed tomography revealed an extremely thickened gallbladder wall. Endoscopic retrograde cholangiopancreatography demonstrated that the main pancreatic duct joined the nondilated common bile duct at the outer point of the duodenal wall (P-C type of pancreaticobiliary maljunction), and the cystic duct joined the common channel directly. The intraoperative amylase levels of the bile juices both in the common bile duct and the cystic duct were high. A cholecystectomy was performed. The wall of the gallbladder was markedly thick, yellowish, elastic, and soft. Histologically, Rokitansky-Aschoff sinus proliferation, hypertrophy of smooth muscles, and fibrosis were seen. The diagnosis was a generalized type of adenomyomatosis. The pathogenesis of the adenomyomatosis was believed to result from chronic stimulation as a result of pancreatic juice reflux. The etiology of this unusual type of junction was considered to be the result of the combination of pancreaticobiliary maljunction and an anomaly of lower junction of the cystic duct.     

Absence of the common bile duct and junction of the cystic duct with the left hepatic duct in a patient with chronic portal vein thrombosis

A50-year-old male patient was admitted to the hospital because of fatigue and a palpable abdominal mass. The diagnoses of chronic renal failure and portal vein thrombosis were established by specific investigations. Incidentally, junction of the cystic duct with the left hepatic duct and absence of the common bile duct were found during endoscopic retrograde cholangiopancreatography study. To the authors' knowledge, this is the first reported case of an absence of the common bile duct and junction of the cystic duct with the left hepatic duct in a patient with chronic portal vein thrombosis. Such lesions may cause unexpected complications during biliary surgery.     

Right hepatic duct opening into the cystic duct: the role of pre- and intraoperative cholangiography

Although an aberrant hepatic duct entering the cystic duct is not especially rare, the main right hepatic duct entering the cystic duct is extremely rare. A 69-year-old woman developed severe intermittent right upper quadrant pain and high fever. A diagnosis of acute calculus cholecystitis was made by radiographic examinations. Magnetic resonance cholangiopancreatography demonstrated dilatation of the right hepatic duct, but could not identify the junction of the right hepatic duct and the cystic duct. Endoscopic retrograde cholangiopancreatography established that the right hepatic duct joined the cystic duct and that cholecystolithiasis was present. As the right hepatic duct entering the cystic duct can lead to ductal injury, this anomaly should be kept in mind when performing laparoscopic cholecystectomy. Pre- and intraoperative cholangiography contribute to the avoidance of iatrogenic bile duct injury. When the right hepatic duct drains into the cystic duct, the gallbladder should be removed distal to the junction of the hepatic and cystic ducts.     

Successful pancreatic duct-to-jejunum anastomosis in a patient with a double pancreatic duct: usefulness of intraoperative ultrasonography (IOUS) and IOUS-guided pancreatography

We treated a patient with cancer of the papilla of Vater associated with an infrequent pancreatic duct course. With a preoperative endoscopic retrograde cholangiopancreatography, the presence of a double pancreatic duct was found. These ducts were bifurcated at the pancreatic body. Intraoperative ultrasonography and intraoperative ultrasonography-guided pancreatography were performed during the surgery. These procedures clarified the tumor extension and exact location of the duct bifurcation. The confirmation of the location of the duct bifurcation enabled to prevent the inadvertent suture of the second pancreatic duct or leaving the second duct without an anastomosis, which would have resulted in the leakage of the pancreatic juice and serious complications, to be avoided.     

Aberrant hepatic duct connected with the main pancreatic duct by anomalous pancreato-biliary ductal union: Case report

An aberrant hepatic duct directly connected to the main pancreatic duct with anomalous arrangement of the pancreato-biliary ductal system is reported here, the first report of such a case, to our knowledge. A 53-year-old woman was admitted to our hospital because of cholecystolithiasis with abdominal pain in the right upper quadrant. Endoscopic retrograde cholangiopancreatography (ERCP) showed that an aberrant hepatic duct, which independently drained the right posterior segment of the liver, connected to the main pancreatic duct at a high insertion site distal to the sphincter area of the major papilla. The common bile duct (containing stones), on the other hand, united with the main pancreatic duct in a normal fashion. Cholecystectomy and bile duct lithotomy were performed. The aberrant hepatic duct was separated from the main pancreatic duct just above the junction, and was anastomosed side-by-side to the common hepatic duct. The embryologic development of this lesion is not clear, but is discussed in this report.     

Sequential progression and intraductal spread of invasive ductal adenocarcinoma of the pancreas arising from around the main pancreatic duct

A 76-year-old woman was admitted to our hospital after increased transaminase, hepato-biliary enzyme levels, and tumor markers were found. Abdominal contrast computed tomography revealed a mass (20 x 18 mm) in the uncus of the pancreas. Magnetic resonance cholangiopancreatography showed an abrupt narrowing with the dilatation of the peripheral main pancreatic duct (MPD) in the pancreatic head. Endoscopic retrograde cholangiopancreatography showed only dilatation of the lower bile duct; insertion of the cannula was not seen because the MPD was obstructed. The patient underwent a Whipple-pancreatoduodenectomy. Histopathological and immunohistochemical examinations led to a diagnosis of sequential progression and intraductal spread of invasive ductal adenocarcinoma of the pancreas arising from around the main pancreaticduct. Interestingly, the intraductal spread was approximately 20 mm to the point where the carcinoma began to infiltrate. To the best of our knowledge, there have been no other reported cases of such broad intraductal spread, indicating that noninvasive lesions that replace the normal epithelia can be broader than those reported previously.     

Atypical ductal hyperplasia of the pancreas associated with a stricture of the main pancreatic duct

Atypical ductal hyperplasia of the pancreas is thought to be a precancerous lesion. We report a case of atypical ductal hyperplasia associated with a stricture of the main pancreatic duct. A 70-year-old man was admitted to our hospital because of abdominal pain with an elevated serum pancreatic isoamylase level. Endoscopic retrograde cholangiopancreatography disclosed a stricture of the main pancreatic duct in the body of the pancreas. Cytological evaluation of endoscopic brushings suggested adenocarcinoma. Distal pancreatec-tomy was performed. Microscopic examination of the stenotic pancreatic duct showed a hyperplastic epithelium without atypia. Atypical hyperplasia, however, was found in the distal portion of the main pancreatic duct in close proximity to the stricture. Atypical hyperplasia extended along the main pancreatic duct into the ductal branches of the pancreatic tail. In contrast to the vast majority of patients with atypical hyperplasia, the atypical hyperplasia seen in the present patient had no histological features suggestive of intraductal extension of the invasive carcinoma or intraductal papillary-mucinous tumor, thus representing a sporadic precancerous lesion, and it may have been equivalent to carcinoma in situ. Pancreatic duct stricture and the resultant stasis of the pancreatic juice may have promoted the atypical changes in the ductal cells upstream of the stricture. Received: August 20, 2001 / Accepted: February 8, 2002 Reprint requests to: M. Kogire Editorial on page 311     

Intraductal papillary mucinous tumor of the pancreas: computerized tomography and magnetic resonance imaging features

The aim of this study was to analyze the computerized tomography (CT) and magnetic resonance imaging (MRI) features of intraductal papillary mucinous tumor (IPMT) of the pancreas. The cases of eight patients with pathologically proven IPMT (1 papillary hyperplasia, 7 adenocarcinoma) of the pancreas were retrospectively reviewed. There were five men and three women with ages ranging from 42 to 82 years. Imaging studies included six thin-section dynamic CT scans, seven MRI scans, one MR cholangiopancreatography scan, and two endoscopic retrograde cholangiopancreatography scans. There was only one benign IPMT, which presented as a unilocular cyst in the pancreatic body with no mural nodules and no dilatation of the main pancreatic duct (MPD). All seven patients with malignant IPMT had multilocular cysts with papillary projections in the pancreatic head and/or uncinate process accompanied by dilated MPD (5 diffuse, 2 segmental). Communication between the cystic lesions and the MPD were evident in all seven patients. One patient had small mural nodules in the branch ducts of the pancreatic body and five had a bulging papilla with a patulous orifice. A mass effect resulting in biliary obstruction was shown in one patient. One patient had a ruptured cyst with mucin leakage into the right anterior pararenal space following sono-guided aspiration. In conclusion, the main imaging feature of IPMT in our patients was a multilocular cyst with papillary projections located in the pancreatic head and uncinate process. Although CT and MRI cannot differentiate mucin content from pancreatic juice, communication between the cystic lesion and the dilated MPD and a bulging papilla with a patulous orifice are characteristics of IPMT.     

A case of macrocystic serous cystadenoma of the pancreas

Summary A case of macrocystic serous cystadenoma of the pancreas is presented, and literature is reviewed. A 35-yr-old woman presented with mild upper abdominal pain. Abdominal ultrasonography and an abdominal computed tomography revealed a multiloculated and calcified cyst in the body of the pancreas. A T1-weighted image, using magnetic resonance imaging, revealed a low-intensity mutiloculated, pancreatic mass. In contrast, T2-imaging of the tumor showed a high-intensity mass. Endoscopic retrograde cholangiopancreatography showed no contact between the main pancreatic duct and the tumor. The preoperative diagnosis was a mucinous cystic neoplasm. Tumor enucleation was performed. Subsequent microscopic examination of this tumor suggested the diagnosis of a macrocystic serous cystadenoma of the pancreas.     

Hemorrhage from bile duct varices treated with fully covered expandable metallic stent placement in pancreatic carcinoma

A 64-year-old woman with unresectable pancreatic body carcinoma was admitted with epigastralgia with a sudden onset 6 h earlier. She had received chemotherapy for her cancer for 2 months. Physical examination showed mild anemia. Contrast-enhanced computed tomography showed dilated vessels in the bile duct walls connecting with dilated and tortuous vessels around the extrahepatic bile duct and portal vein obstruction due to invasion by a pancreatic body tumor. Endoscopic examination showed transpapillary hemorrhage suggesting bile duct hemorrhage. On endoscopic retrograde cholangiopancreatography, the lower bile duct was filled with a mass and the middle bile duct had filling defects with compression of the wall. To stop the bleeding, we placed a fully covered expandable metallic stent (EMS) at the middle to lower portion of the bile duct, and the hemorrhage stopped. Bile duct hemorrhage is not a common disorder. This report shows bile duct hemorrhage from bile duct varices can occur in patients with pancreatic carcinoma with portal obstruction and that fully covered EMS placement can stop the hemorrhage.