Endoscopic Ultrasound (EUS) Findings in Tropical Pancreatitis

Abstract

Introduction: Tropical Pancreatitis (TP) is an idiopathic Chronic Pancreatitis (CP) unique to nonindustrialized countries. Large intraductal calculi, marked dilatation of the main pancreatic duct, and gland atrophy, characterize it. This is the first report describing Endoscopic Ultrasound (EUS) features.FigureCase: A 26 YOF recently arrived from South India, presented with epigastric pain radiating to the back, nausea and vomiting of 5 days duration. She has had similar episodes since age 15. They usually resolve within 4–5 days with restricting diet, antiemetics and painkillers. Previous EGD showed doudenitis and she was treated for H Pylori. There was minimal ETOH use and no family history of a similar condition or of GI malignancies. Lipase was 87. Triglyceride levels were normal. CT scan of the abdomen showed an ill-defined pancreas with surrounding inflammatory changes, a dilated pancreatic duct, and multiple calcifications. EUS of the pancreas showed parenchymal calcifications, hyperechoic strands, hyperechoic foci, lobularity, and cysts. The pancreatic duct was dilated, up to 6 mm, with hyperechoic walls, visible side branches, with a tortuous/ecstatic appearance. Discussion: EUS is increasingly being utilized to diagnose diseases of the pancreas; including CP. EUS features of CP are echogenic foci, strands, lobularity, cysts, stones, duct dilatation, duct irregularity, hyperechoic duct margins, and visible side branches. These features were all present in our patient, consistent with CP. TP, first described by Geevarghese, as a disease with pain during childhood, diabetes during puberty, and with death occurring at the prime of life. It initially was thought to be restricted to areas within 30° of latitude from the equator. More than 90% of patients have the illness before 40 years. The overall prevalence in an endemic area is 1 in 500 to 1 in 800 in Southern India. Endocrine insufficiency is an inevitable consequence. The pathophysiology of TP is unknown. Genetic mutations of the SPINK1 gene, particularly the N34S missense mutation, are seen in up to 50%. Conclusion: EUS features of TP are similar to those of CP, in our patient, who demonstrated all 9 features.[figure1]