Solitary pancreatic tuberculosis mimicking advanced pancreatic carcinoma

A 40-year-old woman was referred for pancreatic head carcinoma invading the portal vein. The dichotomy between the radiological findings and the general condition of the patient, as well as the laboratory results (no evidence of cholestasis), cast doubt on the diagnosis. There was no history of tuberculosis. The chest radiograph revealed no pathological findings. The anatomic relationships of the lesion entailed a high risk of vascular injury if tissue biopsy were to be done; therefore, diagnostic laparotomy was performed. Biopsy revealed granulomas with caseous necrosis, consistent with tuberculosis. After 6 months of antituberculosis treatment, the lesions had completely resolved. Tuberculosis should be considered in the differential diagnosis of pancreatic masses, particularly in regions where the disease is endemic. The condition usually resembles an advanced pancreatic tumor. Performing a biopsy of inoperable lesions and maintaining a reasonable skepticism in regard to the evaluation of operable lesions (attention to nonexclusive but helpful clues, such as young patient age, history of tuberculosis, absence of jaundice) will lead to the diagnosis in most patients. Diagnostic laparotomy may be required in a small subset of patients. The response to antituberculosis treatment is very favorable. The role of resection (e.g., pancreatoduodenectomy) is very limited.     

Coexistence of pancreatic carcinoma and pancreatic tuberculosis: case report

Pancreatic tuberculosis (TB) is extremely rare and mimics pancreatic carcinoma both clinically and radiologically. This paper discusses the occurrence of 2 heterogeneous masses located in the head and tail of the pancreas in an adult male. In this patient, laparotomy was performed because of the high suspicion of pancreatic carcinoma. Intraoperative fine needle aspiration biopsy revealed the coexistence of pancreatic carcinoma with pancreatic TB, and a combined resection of the distal pancreas and spleen was successfully performed. Following surgery, the patient received standard chemotherapy for TB. At 7-month follow-up, computed tomography showed resolution of the mass in the pancreatic head. Clinicians must maintain a high index of suspicion for pancreatic TB in patients with pancreatic masses. The coexistence of malignancy and TB should be considered when patients present with multiple pancreatic masses.     

Ultrasound-guided percutaneous pancreatic tumor biopsy in pancreatic cancer: a comparison with metastatic liver tumor biopsy, including sensitivity, specificity, and complications

Background The aims of this study were to investigate the diagnostic value and safety of ultrasound-guided percutaneous pancreatic tumor biopsy (pancreatic biopsy) in patients with suspected unresectable pancreatic cancer, and to compare the data with those obtained by metastatic liver tumor biopsy (liver metastases biopsy). Methods Data were collected retrospectively from 388 patients (398 procedures) for whom a final diagnosis was available and who underwent ultrasoundguided pancreatic or liver metastases biopsy with a 21-gauge needle (core biopsy) or a 22-gauge needle (fine-needle aspiration biopsy: FNAB). The sensitivity, specificity, and accuracy of pancreatic and liver metastases biopsies were evaluated. Biopsy-related complications were collected and analyzed. Results Data from 271 pancreatic and 112 liver metastases biopsy procedures were available. For pancreatic core biopsy and FNAB, the sensitivity, specificity, and accuracy were 93%, 100%, and 93%, and 86%, 100%, and 86%, respectively, all of which were comparable to those of liver metastases biopsy. The complication rate in pancreatic biopsy was 21.4%, including a 4.4% incidence of post-biopsy ephemeral fever. The complication rate in liver metastases biopsy was 38.7%, including an 8.0% incidence of ephemeral fever. Fever and infection occurred more frequently among patients who underwent liver metastases biopsy (4.4% vs. 11%: P = 0.038). In pancreatic biopsy cases, a prebiopsy high serum total bilirubin level was a statistically significant predictor of ephemeral fever. Conclusions Ultrasound-guided percutaneous pancreatic biopsy is an effective and safe modality for confirming the pathologic diagnosis in patients with unresectable pancreatic cancer.     

Management of pancreatic mass accompanying chronic pancreatitis

We report two patients with focal, chronic pancreatitis that was diagnosed by dynamic computed tomography (CT) combined with intraoperative biopsy. In case 1, serum carbohydrate antigen (CA) 19‐9 level rose to 160–U/ml. Abdominal ultrasonography, CT, and magnetic resonance imaging demonstrated a mass, of 4.5–cm in diameter, in the pancreatic head. On dynamic CT, the mass was enhanced similarly to the normal pancreatic parenchyma. In case 2, dynamic CT demonstrated a mass, of 3.0–cm in diameter, in the pancreatic head, which was enhanced similarly to the normal pancreatic parenchyma. From such characteristics of enhancement, both masses were suspected to be chronic pancreatitis rather than cancer, and the diagnosis was confirmed by intraoperative biopsy. Three years in case 1 and 2 years in case 2 have passed since their operations, and the size of each mass has not changed. With the use of dynamic CT combined with intraoperative biopsy, focal chronic pancreatitis could be diagnosed more accurately, and this may lead to a reduction in unnecessary pancreatic resection.     

Isolated tuberculosis of the pancreas diagnosed with needle aspiration: a case report and review of the literature.

Pancreatic tuberculosis is very rare, especially in immunocompetent patients, and represents a diagnostic challenge. The clinical features in patients with pancreatic tuberculosis are usually non-specific. The radiological features mimic pancreatic malignancy or pancreatitis. We describe a case of pancreatic tuberculosis mimicking carcinoma on Computed tomography scan. Ultrasound guided fine needle aspiration cytology (FNAC) showed caseating granulomatous inflammation. The diagnosis of pancreatic tuberculosis was made and the patient was put on anti-tubercular therapy. Five months later, a repeat CT scan of the abdomen revealed resolution of the pancreatic lesion. We emphasize that tuberculosis should now be included in the differential diagnosis of a pancreatic mass. Diagnostic indicators include the association of a pancreatic mass with fever, the presence of abdominal pain and a cystic pancreatic mass in a younger patient coming from a region where tuberculosis is endemic.     

Tuberculosis of the Pancreas: Report of Three Cases

Three cases of pancreatic tuberculosis are described. The first patient presented with abdominal pain, weight loss, anorexia., vomiting, hepatomegaly, and mass in the head of the pancreas, on computerized tomographic (CT) scan. The second patient presented with low grade fever, anorexia, and weight loss, and was investigated for gallbladder disease. The third patient presented with obstructive jaundice and mass lesion in the head of the pancreas. Two patients underwent laparotomy for suspected pancreatic tumors. The findings of pancreatic disease was incidental during laparotomy in the second patient. The histopathology revealed caseating granuloma in all of them. The first patient responded well to treatment, and the second patient stopped treatment after 2 months and is well. The third patient is being followed. If malignancy can be ruled out, tuberculosis should be considered in relevant geographic areas, and a tissue diagnosis should be made.     

Combined use of endoscopic retrograde cholangiopancreatography and computed tomography for identifying pancreatic abscesses

A 40-year-old male showed intermittent spike fever 2 1/2 months after receiving conservative medical treatment for acute pancreatitis. Endoscopic retrograde cholangiopancreatography (ERCP) revealed leakage of the contrast media from the main pancreatic duct into the pancreatic parenchyma. Immediately following ERCP, computed tomography (CT) scans revealed separate poolings of this contrast media in the pancreatic head and tail. Surgical debridement of the pancreatic head and tail was therefore performed, after which drains were placed at both sites. The patient recovered successfully. To own knowledge, this is the first reported case in which pancreatic abscesses, a late complication of acute pancreatitis, were clearly identified by the use of ERCP followed by CT.     

Diagnosis of pancreatic tuberculosis by combined, contrast-enhanced sonography and endoscopic ultrasound-guided fine-needle aspiration

A 79-year-old woman complaining of epigastric pain was examined by her local physician, who found an abdominal mass and referred the patient to our department. Abdominal plain computed tomography revealed a mass, 50 mm in size, with slight calcification on the ventral side of the head of the pancreas. On abdominal ultrasound, the mass lesion consisted of an aggregation of hypoechoic masses, with a heterogeneous hyperechoic region at its center. On contrast ultrasonography, only the hyperechoic region was stained. ¹⁸F-Fluorodeoxyglucose-positron emission tomography (FDG-PET) revealed FDG accumulation in the same region. It was difficult to differentiate between a malignant pancreatic tumor and an inflammatory disease on imaging, but since QuantiFERON TB2G testing was positive, pancreatic tuberculosis was suspected, and endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA) was performed to obtain a definitive diagnosis. Samples from the hypoechoic region consisted of necrotic tissue, while those from the hyperechoic region consisted of pancreatic tissue together with granulation tissue. BCG immunostaining was positive, and a diagnosis of pancreatic tuberculosis was made. If EUS-FNA is performed on stained areas seen on contrast ultrasonography, this will probably enable a more accurate diagnosis of pancreatic tuberculosis with low invasiveness.     

Duodenum preservation in pancreatic head resection to maintain pancreatic exocrine function (determined by pancreatic function diagnostant test and cholecystokinin secretion)

Background/Purpose

Organ-preserving surgery, such as pylorus-preserving pancreatoduodenectomy (PPPD), duodenum-preserving pancreatic head resection (DPPHR), or medial pancreatectomy (MP), is one of the recent advances in pancreatic surgery. There was a previous report that preservation of the duodenum maintained pancreatic function. However, concerning the resected pancreas, patients were divided into two groups; one group included pancreatic head resections such as Whipple, PPPD, and complete DPPHR, and the other group included MP that removed only the pancreatic neck and preserved the pancreatic head and distal pancreas. The present study was designed to clarify the significance of duodenum preservation, in comparison with duodenum removal, in patients with pancreatic head resection, in terms of pancreatic function, determined by a pancreatic function diagnostant (PFD) test and cholecystokinin (CCK) secretion.

Methods

The subjects were 61 patients (10 with Whipple, 41 with PPPD, and 10 with complete DPPHR). PFD tests and postprandial plasma CCK secretion were used for evaluation.

Results

There was a significant difference between pre- and postoperative PFD values in the patients who received Whipple or PPPD; however, there was no difference in those who had complete DPPHR. Concerning the postoperative PFD value, complete DPPHR was superior to Whipple and PPPD. Regarding postprandial CCK secretion, the pre- and postoperative values were significantly different in the patients with Whipple or PPPD, but there was no difference in those with complete DPPHR. Comparing the three kinds of operations, complete DPPHR was superior to the other two procedures in its maintenance of pancreatic function. There was the significant correlation between CCK and PFD in our patients in the Spearman Rank Correlation (P < 0.0029) and Fisher’s r to z (P < 0.0058).

Conclusions

When pre- and postoperative pancreatic exocrine function and postprandial CCK secretion were measured in patients with pancreatic head resection, it was found that preservation of the entire duodenum was an important factor for maintaining pancreatic function.     

Pancreatic Tuberculosis with a Pancreaticobiliary Fistula

Pancreatic tuberculosis (TB) is a rare condition that is sometimes difficult to differentiate from pancreatic cancer or other malignancies. A 75-year-old man was admitted to our hospital because of weight loss, fever, and diarrhea. Abdominal ultrasonography and computed tomography (CT) revealed a 3-cm mass in the pancreas head with abdominal lymphadenopathy. Endoscopic retrograde cholangiopancreatography did not show pancreatic duct stenosis or dilatation, but a pancreaticobiliary fistula was demonstrated. Cytological and bacteriological examinations of the pancreatic juice and bile were negative. Endoscopic ultrasonography-guided fine needle aspiration of the mass was not diagnostic. Colonoscopic features and biopsy specimens affirmed the diagnosis of TB, and treatment with antitubercular drugs was started. The pancreatic mass disappeared within 8 weeks and the pancreaticobiliary fistula resolved.     

Primary tuberculosis of the pancreas mimicking a pancreatic tumor.

BACKGROUND: Diagnosis of tuberculosis of the pancreas is often missed, and may present to the clinician as a difficult diagnostic problem. METHODS: We report an extremely rare case of a 35-year-old woman who admitted for acute pain in the right upper quadrant, jaundice, fever 38 degrees C and chills. During the last 8 mo, she developed increasing fatigue and a weight loss of approx 10 kg. RESULTS: Computed tomography (CT) of the abdomen showed a mass in the head of the pancreas, and upper gastrointestinal endoscopy revealed a stenosis of the second part of duodenum and a pancreatico-duodenum fistula. Frozen sections by direct trucut needle biopsy raised suspicions of a malignancy, and a Whipple procedure was performed as a radical procedure. The final histopathology revealed a chronic granulomatous lesion with caseating necrosis. Mycobacterium of tuberculosis was detected using the polymerase chain reaction-based assay. CONCLUSION: This unusual case emphasizes that in suspected cases of pancreatic carcinoma with an atypical presentation, an attempt should be made to confirm the diagnosis by CT-guided needle biopsy, or by ultrasound endoscopic fine-needle aspiration.     

PANCREATIC TUBERCULOSIS AND ITS DIAGNOSIS BY ENDOSCOPIC ULTRASONOGRAPHY: REPORT OF TWO CASES AND REVIEW OF THE LITERATURE

Mass lesions in the head of the pancreas are generally malignant and it is difficult to diagnose benign lesions preoperatively. We describe two patients with pancreatic tuberculosis, who presented with abdominal pain, jaundice and a pancreatic head mass, mimicking cancer. The correct diagnosis could be made by endoscopic ultrasonography (EUS) and EUS‐guided fine‐needle aspiration (FNA) cytology in both patients, precluding the need for surgery. Both patients responded well to anti‐tuberculosis treatment. We conclude that EUS with guided FNA is a useful modality to diagnose pancreatic tuberculosis.     

Primary Tuberculosis of the Pancreas Mimicking a Pancreatic Tumor

Summary Background. Diagnosis of tuberculosis of the pancreas is often missed, and may present to the clinician as a difficult diagnostic problem. Methods. We report an extremely rare case of a 35-year-old woman who admitted for acute pain in the right upper quadrant, jaundice, fever 38°C and chills. During the last 8 mo, she developed increasing fatigue and a weight loss of approx 10 kg. Results. Computed tomography (CT) of the abdomen showed a mass in the head of the pancreas, and upper gastrointestinal endoscopy revealed a stenosis of the second part of duodenum and a pancreatico-duodenum fistula. Frozen sections by direct trucut needle biopsy raised suspicions of a malignancy, and a Whipple procedure was performed as a radical procedure. The final histopathology revealed a chronic granulomatous lesion with caseating necrosis. Mycobacterium of tuberculosis was detected using the polymerase chain reaction-based assay. Conclusion. This unusual case emphasizes that in suspected cases of pancreatic carcinoma with an atypical presentation, an attempt should be made to confirm the diagnosis by CT-guided needle biopsy, or by ultrasound endoscopic fine-needle aspiration.     

Role of endoscopic ultrasound guided FNAC in diagnosis of pancreatic TB presenting as mass lesion: a case report and review of literature

A 24-year-old male patient presented with abdominal pain, obstructive jaundice, anorexia and weight loss. Ultrasound abdomen revealed pancreatic head mass with dilated common hepatic duct and intrahepatic bliliary radicles. CECT abdomen was suggestive of pancreatic head mass invading portal vein, splenic artery and hepatic artery. Provisional diagnosis of unresectable carcinoma head of pancreas was established. Endoscopic ultrasound (EUS) was done, which was also suggestive of pancreatic head mass infiltrating portal vein. EUS guided Fine Needle Aspiration Cytology (FNAC) was taken with an intent to obtain tissue diagnosis and to start palliative chemotherapy. EUS guided FNAC features were suggestive of tuberculosis (TB). Patient was started on anti-tubercular therapy, to which he responded and was cured. Pancreatic tuberculosis should be considered as a possibility, in pancreatic mass, especially in countries where TB is endemic and establishing its diagnosis with the aid of FNAC can save trauma of major surgery to the patient, which prompted us to report this case.     

A pancreatic abscess 7 years after a pancreatojejunostomy for calcifying chronic pancreatitis

We present herein a case of a 75-year-old Japanese man who had developed a pancreatic abscess 7 years after a longitudinal pancreatojejunostomy for chronic pancreatitis. The patient, a heavy drinker of alcohol, underwent surgical decompression of a ductal obstruction to relieve persistent abdominal pain due to severely calcifying chronic pancreatitis. After the surgery, he stopped drinking alcohol and was treated with insulin to control secondary diabetes mellitus. Thereafter, his symptoms disappeared. Seven years after the surgery, however, he was hospitalized due to obstructive jaundice, high-grade fever, and right hypochondria pain. Ultrasound and computed tomographic scans of the abdomen both disclosed a cystic mass, approximately 6 cm in size, in the pancreatic head. Magnetic resonance imaging strongly suggested a pancreatic abscess with necrotic fluid and debris. First, percutaneous transhepatic cholangiodrainage (PTCD) was done to treat the progressively obstructive jaundice. Subsequently, fine-needle aspiration of the pancreatic abscess was performed under ultrasound guidance. Enterococcus avium and Klebsiella oxytoca were revealed by culture of abscess aspirates. He was successfully cured by treatment with both appropriate antibiotic and continuous PTCD for the obstructive jaundice. Received: April 3, 2001 / Accepted: August 10, 2001     

Patient allocation based on preoperative assessment of pancreatic fibrosis to secure pancreatic anastomosis performed by trainee surgeons: a prospective study

Background

A fragile or non-fibrotic pancreas increases the risk of postoperative pancreatic fistula (POPF) after pancreatic head resection, whereas pancreatic fibrosis decreases the risk. The degree of pancreatic fibrosis can be estimated using the time-signal intensity curve (TIC) of the pancreas, obtained with dynamic magnetic resonance imaging (MRI). We have investigated whether trainee surgeons can perform pancreatic anastomosis safely, without the occurrence of POPF, when patients are selected carefully based on a preoperative assessment of pancreatic fibrosis.

Methods

Seventy-two consecutive patients who underwent pancreatic head resection were enrolled in this prospective trial. Dynamic contrast-enhanced MRI of the pancreas was performed preoperatively in all patients who, based on their pancreatic TIC profile, were then allocated to one of two groups: Group A comprised patients with type I pancreatic TIC, signifying a normal pancreas without fibrosis (n = 46); Group B comprised patients with type II or III pancreatic TIC, signifying a fibrotic pancreas (n = 26). An end-to-side duct-to-mucosa pancreaticojejunostomy was performed in all patients, with all patients in Group A operated on by two experienced surgeons, and all patients in Group B operated on by one of eight trainee surgeons at various stages of training.

Results

There was no operative mortality. POPF developed in 19 patients: 12 patients with grade A POPF and seven with grade B. All except one of the POPF occurred in Group A patients. The POPF in the one patient from Group B was grade A (p < 0.001).

Conclusions

A trainee surgeon can perform a secure pancreatic anastomosis without the occurrence of POPF in patients with a pancreas displaying a fibrotic pancreatic TIC on dynamic MRI scans.     

Endoscopic ultrasonography guided pancreatic pseudocysts drainage by self-made stent

AIM Endoscopic ultrasonography (EUS) guided pancreatic pseudocysts drainage is an ideal therapeuticprocedure. We perform it in just one step by using the self-made drainage stent.ETHODS We made an aperture at the tip of the needle outer sheath, and tied the outer sheath with theself-made stent by suture. EUS-guided pancreatic pseudocysts drainage was performed in five patients. Nopatient had visible endosmotic bulge on the gastrointestinal wall. Mean pseudocyst diameter was 4.5 cm(pancreatic head 1, body 2, tail 4). We determined the optimal site for puncture and advanced the needlyand stent into cyst. Taking out the needle made the stent separated from the sheath.RESULTS No hemorrhage happened among these patients. One patient suffering from fever up to 40℃recovered within two days after operation. All the cysts diminished insige after 7 days and resolvedcompletely after 6.8 weeks in average. Cyst resolution was accompanied by symptomatic improvement in allpatients. During a follow-up of 6 months no cyst recurred.CONCLUSION EUS-guided drainage of pseudocysts is a safe and effective procedure, which performs thejust in one process and diminishes the patients' distness.     

Isolated Tuberculosis of the Pancreas Masquerading as a Pancreatic Mass

A 65-yr-old woman presented For evaluation of a pancreatic mass. She had been Suffring from severe constitutional symptoms for 18 months; those symptoms included weight loss, increasing fatigue, night sweats. and recurrent fever attacks up to 40°C. Later, bluish subcutaneous nodules developed on her lower limbs. Laboratory tests yielded signs of chronic inflammation and impaired glucose tolerance with elevated serum insulin and glucagon concentrations. Skin biopsy revealed lobular panniculitis. Ultrasonography and a CT scan demonstrated enlargement of the pancreas, and endo-scopic retrograde pancreaticography disclosed displacement and stenosis of the main pancreatic duct. The patient was referred for explorative laparotomy, which was highly suggestive of a malignant pancreatic tumor. However, histological examination of the resected pancreatic and peri pancreatic mass revealed tuberculous pancreatitis. This form of isolated tuberculous pancreatitis, associated with lobular panniculitis and laboratory features consistent with a tumor of the endocrine pancreas, has not been reported previously. Active tuberculosis should be a leading differential diagnosis in a patient with an enlarged pancreas when the usual diagnostic reasoning does not yield conclusive results.     

Pancreatic tuberculosis: an elusive diagnosis

BackgroundPancreatic tuberculosis is a rare disease. Its presenting features are usually vague and non-specific, while the radiological features mimic pancreatic malignancy in many cases and pancreatitis in others. Ultrasound- or CT-guided fine-needle aspiration cytology (FNAC) or biopsy may show caseating granulomatous inflammation but microbiological confirmation may not always be possible. Laparotomy may be required if other investigations prove inconclusive. The response to treatment is good.Case outlinesWe report two young men with pancreatic tuberculosis. The diagnosis was obtained by FNAC in one and laparotomy in the other. Each patient responded to anti-tuberculous chemotherapy and is now asymptomatic.ConclusionTuberculosis should be considered in the differential diagnosis of an obscure pancreatic mass, and the condition is readily curable.