Chronic pancreatitis resulting from primary hydatid disease of the pancreas: a case report and review of the literature

Abstract

A 24-year-old Jordanian man presented with epigastric pain radiating to the back associated with vomiting; identical episodes had been occurring since age 12 years. He had no weight loss, jaundice or diarrhea, and there was no history of alcohol abuse, abdominal trauma, hyperlipidemia, or family history of pancreatitis. Physical examination revealed an acutely ill man with a temperature of 100° F. The abdominal examination demonstrated hypoactive bowel sounds, epigastric tenderness, and no rebound or guarding. Laboratory data revealed a white blood cell count of 13,700/mm3, a hematocrit of 40%, and 395,000/ mm3 platelets. There was no eosinophilia. His amylase was 571 units/L (normal 25-125), lipase 757 units/L (normal 8-70), and liver function tests were normal. US of the abdomen showed no stones in the gallbladder or biliary ductal dilation but did reveal a dilated pancreatic duct (PD) with calcifications. CT disclosed enlargement of the head of the pancreas with atrophy and calcifications in the body and tail. There was marked dilation of the main PD, and a 2.5 × 3.5 cm cystic lesion was seen projecting from the tail (Fig. 1). A diagnosis of idiopathic chronic pancreatitis and pseudocyst of the pancreas was made and endoscopic therapy was considered. ERCP revealed a dilated main PD with multiple filling defects consistent with stones (Fig. 2). A stricture was seen in the PD in the head, with upstream dilation of the remaining duct. An abrupt “cutoff ” of the duct was observed in the region of the presumed pseudocyst. A PD sphincterotomy to facilitate stone extraction was performed, followed by placement of a 7F × 9 cm PD stent. The cholangiogram was normal. The patient was readmitted for recurrent pain 1 month later, and ERCP was repeated. The PD stent was removed and found to be occluded. Several filling defects thought to be pancreatic stones were again observed, and on sweeping the pancreatic duct with an 11.5 mm balloon-tipped catheter, copious amounts of milky white gelatinous secretions poured out of the papillary orifice. This material had given rise to the filling defects in the duct, as contrast instillation at the termination of the procedure showed a dilated PD but no filling defects. The patient improved clinically, only to return with pancreatitis again, and surgery was consulted. At laparotomy, a cystic mass was present in the body and tail of the pancreas that was adherent to the spleen. A partial pancreatectomy followed by pancreaticojejunostomy was performed. Opening of the cystic mass disclosed a hydatid cyst containing multiple daughter cysts (Fig. 3), and the histopathologic findings were consistent with Echinococcus granulosus. There was a communication between the cyst cavity and the main PD through a defect in the cyst wall. Postoperatively the patient was treated with albendazole at an oral dose of 400 mg BID for 12 weeks. He has remained symptom free to date (12 months).