Isolated ventral pancreatitis in an alcoholic with pancreas divisum

An alcoholic with no history of clinical pancreatitis was found to have pancreas divisum and marked changes of chronic pancreatitis isolated to the ventral pancreas. Pancreas divisum has been suggested to cause recurrent pancreatitis in some patients. Gross and histologic changes of pancreatitis in only the dorsal pancreas of surgically resected specimens from patients with pancreas divisum is thought to support the concept that obstruction at the minor papilla produces dorsal pancreatitis. Alternative explanations for the occurrence of segmental pancreatitis and the possible synergistic role of ethanol and bile are reviewed.     

Pancreatic lymphangioma: CT,MRI, and angiographic features

An unusual case of pancreatic lymphangioma presenting as a large mid-abdominal mass with sunburst pattern of calcification is herein described. The findings noted on computed tomography (CT), magnetic resonance imaging (MRI), and mesenteric angiography are illustrated.     

Solid and papillary epithelial pancreatic neoplasm: An unusual tumor

Solid and papillary epithelial neoplasms of the pancreas are uncommon. These grow to a large size, are often palpable, and occur most often in young black women. The tumors have a characteristic histologic appearance and a low malignant potential. Heavy tumor calcification is an unusual finding. Two cases with radiologie-pathologic correlation are presented herein.     

Gallbladder ectopia simulating pancreatic mass on CT

The authors present an unusual case of a highly mobile gallbladder which simulated a pancreatic mass on computed tomograms. Radiographic features of this interesting variant are illustrated.     

Uneven Lipomatosis: A pitfall in pancreatic Sonography

A marked difference in echogenicity between the anterior and posterior parts of the pancreatic head was demonstrated by pancreatic ultrasound in 4 patients. This finding could not be related to local pancreatic or peripancreatic pathology. In all patients the dorsal portion of the head, including the uncinate process, appeared less echogenic than the ventral part of the head, body, and tail. The level of demarcation was identical in all 4 cases, coinciding with the expected fusion line of the embryological dorsal and ventral pancreatic origin. Pathology available in 1 patient showed an uneven lipomatosis as an explanation for this hitherto unreported observation.     

Duplex ventral pancreas

Complete duplication of the ventral pancreatic ductal system in 2 patients is reported. Both patients, during evaluation for recurrent abdominal pain, underwent endoscopic retrograde cholangiopancreatography that revealed typical changes of chronic pancreatitis and pseudocysts confined to 1 ductal system with the other ductal system completely normal. Both ductal systems filled with contrast medium via a common opening at the major papilla. A rudimentary minor papilla was present, but cannulations were unsuccessful. This unusual anomaly of the ventral pancreas with its embryologic basis, diagnosis, and clinical implications is discussed.     

Rare variant of pancreaticobiliary maljunction associated with pancreas divisum in a child diagnosed and treated by endoscopic retrograde cholangiopancreatography: A case report

BACKGROUND Pancreaticobiliary maljunction(PBM) is an uncommon congenital anomaly of the pancreatic and biliary ductal system, defined as a union of the pancreatic and biliary ducts located outside the duodenal wall. According to the Komi classification of PBM, the common bile duct(CBD) directly fuses with the ventral pancreatic duct in all types. Pancreas divisum(PD) occurs when the ventral and dorsal ducts of the embryonic pancreas fail to fuse during the second month of fetal development. The coexistence of PBM and PD is an infrequent condition.Here, we report an unusual variant of PBM associated with PD in a pediatric patient, in whom an anomalous communication existed between the CBD and dorsal pancreatic duct.CASE SUMMARY A boy aged 4 years and 2 mo was hospitalized for abdominal pain with nausea and jaundice for 5 d. Abdominal ultrasound showed cholecystitis with cholestasis in the gallbladder, dilated middle-upper CBD, and a strong echo in the lower CBD, indicating biliary stones. The diagnosis was extrahepatic biliary obstruction caused by biliary stones, which is an indication for endoscopic retrograde cholangiopancreatography(ERCP). ERCP was performed to remove biliary stones. During the ERCP, we found a rare communication between the CBD and dorsal pancreatic duct. After clearing the CBD with a balloon, an 8.5 Fr 4-cm pigtail plastic pancreatic stent was placed in the biliary duct through the major papilla. Six months later, his biliary stent was removed after he had no symptoms and normal laboratory tests. In the following 4-year period, the child grew up normally with no more attacks of abdominal pain.CONCLUSION We consider that ERCP is effective and safe in pediatric patients with PBM combined with PD, and can be the initial therapy to manage such cases,especially when it is combined with aberrant communication between the CBD and dorsal pancreatic duct.     

Accuracy of endoscopic retrograde cholangiopancreatography (ERCP) in differentiating benign and malignant pancreatic disease

Despite advent of CT and ultrasound, endoscopic retrograde cholangiopancreatography (ERCP) remains useful in the preoperative evaluation of the pancreas. Using radiographic criteria previously described, ERCP was accurate in 90% of 71 patients in differentiating benign from malignant disease. Diagnostic errors were caused by chronic pancreatitis mimicking carcinoma (N=4) and carcinoma developing in a gland with chronic pancreatitis (N=3) missed on ERCP. Chronic pancreatitis was associated with a normal ERCP in 10% (N=4) of patients.     

Deep dorsal penile vein thrombosis in a patient with COVID‐19 infection: A rare complication and the first reported case

COVID‐19 infection may have extrapulmunary manifestations such as blood hypercoagulability that may cause thrombosis in both arterial and venous system. Deep dorsal penile vein thrombosis is very rare, and the most common reason is coagulation disorders. The common observed symptom is penile pain especially during erection and it is diagnosed by ultrasound evaluation of the vein. It is necessary to distinguish deep dorsal penile vein thrombosis from superficial dorsal penile vein thrombosis as it needs anti‐coagulant treatment. In present study, we describe a unique case of the deep dorsal penile vein thrombosis following COVID‐19 infection.     

Pancreatic transplants: secretin-stimulated MR pancreatography

Background

Our study was aimed to evaluate the functional status of pancreatic transplants using dynamic MR pancreatography after secretin stimulation.

Methods

Thirteen asymptomatic patients previously submitted to isolated pancreas (n = 6) or combined kidney–pancreas (n = 7) transplantation, with enteric-portal pancreatic drainage, underwent MR examination at 1.5 T using a phased-array coil. After the acquisition of axial and coronal T1- and T2-weighted sequences, dynamic MR pancreatography was performed using a coronal breath-hold, thick-slab (40–60 mm), single-shot T2-weighted fast spin-echo sequence. After the intravenous administration of secretin (Secrelux^®, Sanochemia; 1 cU/kg body/weight), a single-slice image acquisition was repeated every 30 s up to 15 min. We estimated the calibre changes of the pancreatic ductal system and the filling of the donor’s duodenum on the basis of pancreatic secretion after secretin stimulation, also evaluated by using a mean signal intensity/time histogram in a chosen region of interest including the transplanted pancreas and the connected small bowel.

Results

All patients well tolerated the examination, and no side effects were reported after secretin administration. In 12/13 cases, a significant increase (more than 1 mm) in the diameter of the mean pancreatic duct was observed after secretin stimulation; in all patients, a noticeable filling of the duodenal graft was demonstrated during dynamic MR pancreatography on both qualitative and quantitative analyses.

Conclusions

Dynamic MR imaging after secretin administration allows non-invasive evaluation of exocrine function of the pancreatic transplants and could be used to differentiate patients with graft rejection from those with normal graft function.

     

Pancreatic plasmacytomas in a patient with multiple myeloma: CT and ultrasound findings

Extramedullary plasmacytomas are an unusual manifestation of multiple myeloma. They occur most frequently in tissues or organs rich in reticuloendothelial cells. Pancreatic plasmacytomas are rare, with only a few case reports in the literature. We present the ultrasound (US) and computed tomographic (CT) findings of two pancreatic plasmacytomas in a patient with multiple myeloma     

Innocuous gas collections in pancreatic allografts demonstrated by computed tomography

Over a 4-year period, 6 pancreatic abscesses were found in 37 patients who had combined renal and segmental pancreatic transplants. An additional 4 patients who were nontoxic at the time of their computed tomographic (CT) examinations had innocuous gas collections, either in the pancreatic allograft or the surrounding peripancreatic tissue. The possible etiology of this gas formation is discussed. These collections do not have the same ominous clinical significance as would be expected in abscess formation. Radiological evaluation should include examination of the gastrointestinal tract and voiding cystograms to detect fistula formation. Simultaneous percutaneous aspiration of this area should be performed to rule out an infective process. If this is negative in a nontoxic transplant patient, the radiologist will be in a position to obviate unnecessary surgical intervention.     

Helical CT anatomy of pancreatic arteries

Background: To assess the frequency of visualization of pancreatic arteries in the arterial phase of helical computed tomography (CT). Methods: The visibility of pancreatic and peripancreatic arteries in helical CT images was evaluated in 20 consecutive patients who had no evidence of pancreatic disease. CT examinations were performed by using a continuously rotating CT scanner and intravenous injection of contrast media. The scans were taken 35 s after the start of injection and with a table speed of 3 mm/s. Images were reconstructed in 3-mm section increments. Results: Frequently visualized arteries were the gastroduodenal, anterior and posterior superior pancreaticoduodenal, and right gastroepiploic arteries. Infrequently visualized arteries were the dorsal pancreatic, pancreatica magna, caudal pancreatic, transverse pancreatic, and common, anterior, and posterior inferior pancreaticoduodenal arteries. Conclusion: Helical CT enabled us to recognize small pancreatic arteries, and the evaluation of these arteries should be considered in the staging of pancreatic carcinoma. Received: 6 June 1995/Accepted: 22 July 1995     

Branch duct IPMTs: value of cross-sectional imaging in the assessment of biological behavior and follow-up

Branch duct intraductal papillary mucinous tumors (IPMTs) are increasingly being described and represent a challenge for the physician. Recent imaging modalities, especially computed tomography and magnetic resonance, allow for a correct diagnosis, but IPMTs can manifest with different degrees of cellular atypia so it is very important to be able to establish the biological behavior of the lesion. Sixty-five patients were included in this study: 29 of them underwent surgery, and the other 36 were followed with cross-sectional imaging. Among patients who underwent surgery, 11 had benign lesions and 18 had malignant lesions. Overall sensitivity, specificity, and accuracy in the diagnosis of malignancy for all the cross-sectional imaging techniques were 61%, 81%, and 69%, respectively. Among patients who were followed and had a magnetic resonance cholangiopancreatographic diagnosis of branch duct IPMT with imaging features indicative of benignity, only two showed modifications over the follow-up period. Even considering some important biases (small number of patients and relatively short follow-up), interesting conclusions can be drawn: the imaging diagnosis of malignancy can be trusted, whereas that of benignity cannot be relied upon, but if the signs of malignancy are absent, the slow growth of the lesions justifies watchful follow-up in the correct clinical setting.     

Pancreatic castleman disease: CT findings

Computed tomography findings in a case of pancreatic localization of Castleman disease are presented correlated with histological findings. This is the second observation in the literature of pancreatic involvement with an unusual histological form.     

Lymphoepithelial cyst of the pancreas

Lymphoepithelial cyst of the pancreas is a rare lesion which may mimic a pancreatic pseudocyst or mucinous cystic neoplasm. To our knowledge, this lesion has never been reported in the radiologic literature. We present a patient with lymphoepithelial cyst of the pancreas, and we discuss the radiographic and pathologic findings.     

Esophageal tuberculosis: Findings on barium swallow and computed tomography

Esophageal tuberculosis secondary to tuberculous mediastinal lymphadenopathy is a very unusual presentation of adult tuberculosis. We report a patient presenting with fever of unknown origin and dysphagia. Barium swallow demonstrated esophageal displacement, mucosal ulceration and perforation with a fistulous tract into the mediastinum. CT of the mediastinum gave the most complete delineation of the tuberculous mediastinal lymphadenopathy which surrounded and displaced the esophagus. The fistulous tract extending from the esophagus into the nodal mass was also seen on CT.     

Angiographic evaluation of the abnormal endoscopic pancreatogram

Out of 1,269 pancreatograms, 122 were abnormal. Angiography was performed in these patients. Fifty-five were found to have pancreatic carcinoma. In the remaining 67 patients a false positive angiographic diagnosis of either chronic pancreatitis or pancreatic cancer was made in 11%. In one patient a hemangioma was diagnosed as a pancreatic cyst. The remaining 58 patients all had normal pancreatic angiograms in spite of gross ductal abnormality on endoscopic retrograde cholangiopancreatography (ERCP). All these patients were followed for an average of 19 months and showed no clinical evidence of pancreatic disease. It is suggested that angiography should be considered a complementary examination to ERCP and is particularly useful to exclude carcinoma when the pancreatogram is abnormal.     

Ultrasonic characteristics of pancreatic tumors

The ultrasonic features of 40 pancreatic tumors were analyzed. The tumors were categorized by texture, attenuation, shape, size, and location. Secondary effects of pancreatic duct visualization, biliary stasis, splenic vein involvement, metastases, and ascites were reviewed. Thirty of thirty-one adenocarcinomas had a similar ultrasonic texture consisting of a background of faint, low-level echoes with varying amounts of superimposed coarse echoes. Tumors are detectable prior to enlargement or distortion of the pancreas. Secondary features were present in 94% of the adenocarcinomas. Significant information regarding the possibility and complexity of resection can be provided.     

Intraductal papillary carcinoma of the pancreas

We report a case of intraductal papillary adenocarcinoma of the distal pancreatic duct. Although a rare subgroup of exocrine pancreatic tumors, their diagnosis is an important one in view of their favorable prognosis with pancreatectomy. Because of the established behavior of villous tumors of the colon, to which they are similar histologically, these tumors should be resected, even if biopsy shows benign disease. Patients should be followed radiologically for recurrence or the development of new adenoma following resection.