Clinical Vignettes/Case Reports - Biliary/Pancreas.

Abstract

Groove pancreatitis is a rare type of segmental pancreatitis that can mimic the effects of a mass leading to gastric outlet obstruction. The clinical manifestations as well as the radiographic appearance make this entity a diagnostic challenge. A 61 year old male with a history of heavy alcohol use and multiple admissions for chronic pancreatitis presented with a four day history of nausea and vomiting. Nine months earlier he had been evaluated by his primary care doctor for a one month history of progressive jaundice. Initial workup was notable for a cholestatic elevation in liver enzymes and a direct bilirubinemia. MRCP suggested distal common bile duct stricture. ERCP confirmed this finding and suggested possible cholangiocarcinoma or pancreatic adenocarcinoma. Tumor markers including CA 19-9 and CEA were normal. A biliary stent was placed and jaundice resolved. Subsequent ERCP to exchange the stent revealed chronic calcified pancreatitis and adenopathy in the peripancreatic and porta-hepatis areas with persistent distal common bile duct stricture. Biopsies were taken from the pancreatic head which were suggestive of chronic pancreatitis but were negative for malignant cells. On admission, lab values were consistent with a severe metabolic alkalosis and a cholestatic pattern of hepatic enzyme elevations. Abdominal CT with oral contrast revealed partial gastric outlet obstruction. A nasogastric tube was placed to decompress the stomach. Repeat MRCP was notable for gastric outlet obstruction and a pancreatic head mass involving the second portion of the duodenum. Repeat ERCP showed partial obstruction in the duodenal cap with edematous folds. Biopsies were again taken from the pancreatic head, which were negative for malignancy. The patient underwent PEJ placement for nutrition and placement of a venting PEG tube for oral liquid intake. The patient was started on prednisone 40mg daily to reduce pancreatic inflammation and discharged. He was readmitted five days later with biliary sepsis, and severe gastric outlet obstruction. He was medically managed with antibiotics and hydration and subsequently transferred to the surgical service where he underwent gastrojejunostomy. At three month follow up he reported feeling well, resolved nasuea, and weight gain. A rare condition in the US, groove pancreatitis is associated with male gender and alcohol abuse. Pathogenesis likely involves increased viscocity of pancreatic secretions from alcohol use in susceptible patients, leading to stasis. inflammation, and obstruction of the minor papilla. Case series describing this condition suggest that definitive treatment is pancreatoduodenectomy, however this case demonstrates that pancreatic sparing surgical approaches may be feasible.Figure 1Figure 2Figure 2