Duodenal Wall Thickening Research Articles

Groove pancreatitis has a spectrum of severity and can be managed conservatively

Background & aimsThe natural history of groove pancreatitis is incompletely characterized. Published literature suggests a high rate of surgery. We describe the short- and long-term outcomes in a cohort of patients with groove pancreatitis treated at our institution. MethodsMedical records of patients hospitalized in the University of Pittsburgh Medical Center system from 2000 to 2014 and diagnosed with groove pancreatitis based on imaging were retrospectively reviewed. Clinical presentation and outcomes during index admission and follow-up were recorded. ResultsForty-eight patients with groove pancreatitis were identified (mean age 53.2 years, 79% male). Seventy-one percent were alcohol abusers and an equal number were cigarette smokers. Prior histories of acute and chronic pancreatitis were noted in 30 (62.5%) and 21 (43.8%), respectively. Forty-four (91.7%) met criteria for acute pancreatitis during their index admission. Alcohol was the most common etiology (68.8%). No patient experienced organ failure. The most frequent imaging findings were fat stranding in the groove (83.3%), duodenal wall thickening (52.1%), and soft tissue mass/thickening in the groove (50%). Over a mean follow-up of 5.0 years, seven (14.6%) required a pancreas-related surgery. Patients had a high burden of pancreatitis-related readmissions (68.8%, 69.4/100 patient-years). Incident diabetes and chronic pancreatitis were diagnosed in 5 (13.9% of patients at risk) and 8 (29.6% of patients at risk) respectively. ConclusionsGroove pancreatitis has a wide spectrum of severity; most patients have mild disease. These patients have a high burden of readmissions and progression to chronic pancreatitis. A small minority requires surgical intervention.

S2371 Endoscopic Vacuum Therapy (EVT) for the Successful Treatment of Duodenal Fistula

INTRODUCTION: Perforation is a devastating complication. The solution has always been surgical. At the Minneapolis, we have encountered a case of complicated duodenal ulcer which failed both surgical and radiology interventions. The EVT finally achieved the closure. CASE DESCRIPTION/METHODS: A 65 y/o veteran presented with persistent vomiting and weight loss. Initial CT revealed a large stomach and a duodenal wall thickening. EGD showed a large amount of bezoar, reflux esophagitis, and ulcerated duodenal stricture that only 6mm endoscope could pass. A 15 mm Axio stent was placed in the stricture. The patient’s symptoms improved and the stent was removed after 3 weeks. Two weeks later, the symptoms recurred. NPO and TPN were initiated. Repeat EGD revealed a pin point pylorus that could not be traversed. Liquid contrast was injected. A duodenal fistula between the duodenal bulb and sub-hepatic space was identified. A surgical procedure was then performed consisting of pylorus exclusion, gastro-jejunostomy (GJ), and sub-hepatic drain, Continuous bilious material via the sub-hepatic drain continued. The patient was unable to tolerate any oral intake. A PEG-J tube then was inserted by the Interventional radiology. Afterwards, the patient’s abdominal pain and drainage increased. Another EGD was performed. This time, a wide-open GJ was seen. The tube was found to pass through the suture line of the “excluded pylorus”. There were 2 additional disruptions at suture line. The PEG-J tube was repositioned into the GJ. The 3 open disruptions at the suture lines were cauterized using argon plasma and then closed using two 8mm and one 12mm Ovasco clips. Within a week, the percutaneous drain from the fistula decreased by 80%. But abdominal pain continued. A fifth EGD was performed to initiate EVT. A new PEG-J tube was inserted through the GJ into the duodenum loop. The distal tip loop string of the tube was secured onto the duodenal wall using 3 small endo-clips. High vacuum suction was applied to the J-port. Within a few days, all drainage from the fistula had ceased. A sixth EGD showed that 1 of the 3 Ovasco clips had fallen off so that standard 9mm endoscope could pass. The duodenal bulb was narrowed. The fistula resolved. The PEG-J was removed. DISCUSSION: EVT is a very effective treatment for perforation and fistula. The fundamental basis is to evacuate gastric, bile, and pancreatic secretions near the internal wound. This therapy should be considered as first-line rather than last resort.

S1386 Periampullary Duodenal Diverticulitis and Common Bile Duct Stricture

INTRODUCTION: Periampullary duodenal diverticula (PAD) are frequently asymptomatic but in rare cases can cause diverticulitis, diverticular bleed, obstructive jaundice, cholangitis, acute pancreatitis or recurrent acute pancreatitis. We present a case of periampullary diverticulitis with common bile duct (CBD) stricture. CASE DESCRIPTION/METHODS: A 45-year-old woman with no past history presented with nausea, vomiting and post-prandial upper abdominal pain. Her physical exam was significant for right upper quadrant tenderness. Initial labs showed WBC 15.6 k/mm3, lipase 436 U/L, AST 64 U/L, ALT 246 U/L, alkaline phosphatase 244 U/L and total bilirubin 2.8 mg/dL. Imaging of the abdomen revealed a dilated biliary tree of 1.2 cm, duodenal wall thickening and adjacent fat stranding. She was started on antibiotics. Endoscopic retrograde cholangiopancreatography (ERCP) showed periampullary duodenal diverticulitis with large amounts of pus extruding adjacent to the ampulla. Cholangiogram revealed distal CBD stricture, and dilated common, left and right hepatic ducts. Biliary sphincterotomy was performed, the stricture was brushed and a plastic CBD stent was placed. Her symptoms resolved and her abnormal lab parameters resolved. Cytology from the brushing was negative for malignancy. Magnetic resonance imaging was done and showed normal pancreas. Repeat ERCP seven months later revealed a persistent stricture spanning the distal half of the CBD - brushings were obtained and a stent was placed. Repeat brushings were negative for malignancy, her tumor markers were within normal limits and the patient is waiting for hepatobiliary surgery intervention for the stricture. DISCUSSION: PADs are frequently found during endoscopic evaluation and studies suggest a prevalence of up to 23%. PAD can be a hindrance to cannulation with reported cannulation rates of 61-95% and complications of ERCP did not differ between patients with and without PAD. Our case highlights the importance of recognizing duodenal diverticulitis in the differential diagnosis of cholangitis. In most cases of diverticulitis, antibiotics and sphincterotomy are sufficient to relieve the obstruction and treat the infection. The case presented highlights a persistent stricture as a consequence of extensive scarring from periampullary duodenal diverticulitis. Despite initial management with antibiotics, sphincterotomy and stent placement, some cases require surgical intervention.Figure 1.: Cholangiogram showing stricture spanning the distal half of the CBD.Figure 2.: ERCP showing periampullary duodenal diverticulitis.

The role of sonography in differentiating congenital intrinsic duodenal anomalies from midgut malrotation: emphasizing the new signs of duodenal and gastric wall thickening and hyperechogenicity

The clinical and plain radiographic differentiation of congenital intrinsic duodenal anomalies (atresia, web, stenosis) from intestinal malrotation is not always clear. Although sonography has been documented as an important diagnostic tool in the differentiation of these two entities, its role is still not widely appreciated and it is still not universally utilized in this clinical setting. To assess the usefulness of sonographic features of the duodenal and gastric wall in the differentiation of congenital intrinsic duodenal anomalies from midgut malrotation in a large series of neonates and to compare them with other features on abdominal radiographs, ultrasound and upper gastrointestinal series. Using the surgical database at our tertiary pediatric hospital, we identified neonates who had surgically proven congenital intrinsic duodenal anomalies or malrotation over a period of 15years (2000-2015). We reviewed imaging findings in both groups of neonates (blinded to the final diagnosis) with attention to the echogenicity and thickness of the wall of the duodenum and stomach, the relationship between the superior mesenteric artery and vein, the position of the third portion of the duodenum and the presence of the whirlpool sign. Findings were compared between the groups using the unpaired t-test and Fisher exact test. We included 107 neonates in the study, 40 with a congenital intrinsic duodenal anomaly, 49 with malrotation (36 with volvulus) and 18 with a combination of both. Duodenal and gastric wall thickening and hyperechogenicity were significantly more common in the group with a congenital intrinsic duodenal anomaly compared to those with malrotation (P<0.0001). Conversely, an abnormal relationship between the superior mesenteric artery and vein, abnormal position of the third part of the duodenum, and the whirlpool sign were significantly more common in neonates with malrotation than in those with congenital intrinsic duodenal anomalies (P<0.0001). Duodenal or gastric wall thickening, and increased wall echogenicity are helpful sonographic features in the differentiation of congenital intrinsic duodenal anomalies from malrotation. Evaluation of the duodenal and gastric wall should thus be added to the features routinely assessed on ultrasound examinations in the clinical setting of suspected duodenal obstruction in the neonate.

3239 Gastric Outlet Obstruction in Setting of Acute Cholecystitis With Duodenal Lipoma

INTRODUCTION: Gastric outlet obstruction (GOO) overall incidence has declined after improved treatment of its benign etiologies. The only remote association between GOO and acute cholecystitis is through Bouveret syndrome, which is characterized by a gallstone ileus in setting of a bilioenteric fistula. Duodenal lipomas are very rare, and literature review reveals only 39 cases reported specifically in the second portion of the duodenum. This is the first reported case of GOO occurring in setting of severe acute cholecystitis and duodenal lipomas, with complete resolution after treatment of the acute cholecystitis. CASE DESCRIPTION/METHODS: A 71 year-old male presented for an unrestrained motor vehicle crash with multiple fractures including left femur fracture requiring surgical intervention. CT on admission showed mild gastric distention, 1.2 cm calcified cholelith. One week postoperatively, he complained of new onset right upper quadrant pain, with subsequent nausea and non bloody emesis. His physical exam was positive for Murphy's sign. His vitals showed tachycardia. His labwork revealed increasing leukocytosis from 13K to 43K with concerns for sepsis. Liver chemistries were WNL, except elevated alkaline phosphatase 171. Repeat imaging demonstrated new findings of acute cholecystitis, duodenal wall thickening, duodenal lipomas, and gastric distention with fluid suggesting gastric outlet obstruction, presumably secondary to the inflammatory process. The patient had nasogastric tube decompression with 2.6 liter output, followed by emergent percutaneous cholecystostomy tube. The patient gastrointestinal symptoms, gastric distention, and leukocytosis significantly improved. Then two days later, EGD was notable for LA Grade D esophagitis and two large duodenal lipomas the in second portion. DISCUSSION: To our knowledge this is the first documented case of GOO associated with acute cholecystitis in the setting of duodenal lipoma. With our case we concluded the GOO pathophysiology was dependent on the degree of inflammation from cholecystitis causing worsening intraluminal narrowing in relation to the specific location of the lipoma. Given the entities have varying presentations, clinical suspicion should remain high, and diagnosis relies on successful imaging and endoscopic evaluation. Treatment of the underlying acute cholecystitis should be urgent with either percutaneous cholecystostomy tube or cholecystectomy, if feasible. The excision of the benign duodenal lipoma can be made on a case-by-case basis.

2556 Duodenal Candidiasis Presenting as Mass-Like Lesion: A Rare Presentation

INTRODUCTION: Candida is a normal inhabitant in the GI tract. It is typical for candidiasis to appear in the esophagus and oropharynx in immunocompromised patients. However, candidiasis of the stomach or duodenum is rare. We report a case of a gastric outlet and biliary obstruction due to a duodenal mass-like lesion in the setting of duodenal candidiasis. CASE DESCRIPTION/METHODS: Patient is a 66 year old female with past medical history of diabetes mellitus type 2, hypertension and osteoarthritis who presented to the hospital with progressive non-bloody vomiting, poor oral intake and constipation for two months. She endorsed abdominal pain and yellowing of the eyes and skin. Her vitals on admission were normal. Physical exam was pertinent for diffuse abdominal tenderness and scleral icterus. Her laboratory findings were significant for AST of 137 U/L, ALT of 130 U/L, alkaline phosphatase of 205 U/L, total bilirubin of 8.9 mg/dL and direct bilirubin of 5.3 mg/dL. Abdominal CT scan showed duodenal thickening with possible mass-like lesion causing gastric outlet obstruction. MRI of the abdomen and MRCP only showed duodenal wall thickening. She had a subsequent EGD that showed mild gastric erythema and a mass like lesion in the duodenum hindering the visualization of the papilla. Biopsy results were significant for active chronic duodenitis with presence of Candida albicans. Gastric biopsy was positive for H. pylori infection. The patient was treated with a 21 day course of Fluconazole followed by bismuth based quadruple therapy. Follow-up EGD showed resolution of the duodenal lesion. At two months follow up after treatment, the patient had no symptoms and liver enzymes were normal. DISCUSSION: Candida is part of the normal flora of the GI tract and commonly causes infection in the mouth and esophagus. Stomach and duodenal infections are less common due to their relatively acidic environment creating a harsh environment for the fungal species to grow and cause disease. However, immunocompromised patients and patients on acid suppressive therapy are vulnerable to opportunistic candidal infection. The long standing history of diabetes may have predisposed patient to the infection. In conclusion, our case highlights a rare presentation of a duodenal candidal infection; mass-like lesion causing gastric outlet and biliary obstruction. This case should serve as a reminder to clinicians to keep candidiasis in the differentials for duodenal infections especially in diabetic patients.

Usefulness of Ultrasonography in the Diagnosis of Peptic Ulcer Disease in Children.

PurposeThis study was performed to assess the clinical usefulness of transabdominal ultrasonography (TUS) in detecting peptic ulcer disease (PUD) in children.MethodsTwenty-four patients (19 boys, 5 girls; mean age, 10.6±4.5 years [range, 3.0–17.9 years]) who were admitted to the hospital for acute abdomen or gastrointestinal bleeding and diagnosed with PUD by endoscopy and who underwent TUS were included. Clinical data were retrospectively collected by reviewing patient medical records. Gastric ulcer (GU) was suspected when the gastric wall exceeded 8 mm in thickness and had lost its five-layer structure on TUS. Duodenal ulcer (DU) was suspected if the duodenal wall thickness exceeded 5 mm.ResultsSensitivity of TUS in diagnosing PUD was 66.7% for GU and 38.9% for DU. Mean age and body weight of the 11 patients suspected with PUD on TUS were 10.9±4.4 years and 38.1±17.2 kg, respectively. For 13 patients without suspected PUD, they were 12.1±4.1 years and 39.6±17.0 kg, respectively. There was a significant difference in height, weight, and body mass index between patients who were suspected to have PUD and those who were not suspected on TUS (p=0.014, 0.008, and 0.005, respectively). A significant difference in the sensitivity of TUS in diagnosing PUD was found between patients under 30 kg and those over 30 kg (88.9% and 20.0%, respectively; p=0.003).ConclusionTUS investigation of the stomach and duodenum is an efficient method for PUD detection in children with low body weight. TUS can be used in preliminary diagnostic work-up before further invasive tests.

Acquired Angioedema as Unusual Cause of Recurrent Abdominal Pain

Acquired angioedema is a rare acquired deficiency of C1 inhibitor characterized by subcutaneous edema and/or submucosal edema of the respiratory or gastrointestinal tract. A 52-year old female with a history of chronic urticaria and recently treated Helicobacter pylori infection was admitted for recurrent epigastric abdominal pain with no new or worsening rash. Her medications included cetirizine, ranitidine, and montelukast. Laboratory work up showed normal lipase, transaminases, but mildly elevated ESR 24 mm/Hr and CRP 1.5 mg/dL. Contrast-enhanced CT abdomen showed duodenal and proximal jejunal wall thickening and mesenteric lymphadenopathy. Push enteroscopy with biopsies revealed normal duodenal and jejunal mucosa. She had multiple emergency department visits for abdominal cramping with facial swelling but without any rash, or shortness of breath. Immunological workup showed normal lymphocyte count, ANA titer 1:160, normal dsDNA, anti-Smith antibodies, normal serum immunoelectrophoresis, but low C1q complement (<5 U/mL), low C4 complement (<2 mg/dL), normal C3 complement, low C1 inhibitor (12 mg/dL) and low C1 inhibitor activity (4%); all consistent with acquired angioedema. She initially received intravenous methylprednisone and diphenhydramine without improvement, followed by fresh frozen plasma and subcutaneous icatibant 30 mg with a resolution of symptoms. Non-allergic angioedema is a rare disorder and includes medication induced and C1 inhibitor deficiency. Although mostly hereditary, C1 inhibitor deficiency can be acquired in association with lymphoproliferative disorders, infections, and autoimmune diseases. Acquired angioedema can present as chronic recurrent abdominal pain or mimic an acute surgical abdomen, even in absence of subcutaneous edema. Diagnosis is made by medical history and the level and activity of C4, C1q, and C1 inhibitor during an acute angioedema attack. Treatment options include C1 inhibitor concentrate, fresh-frozen plasma, and icatibant, which is a selective bradykinin receptor antagonist. Long-term prophylaxis is with antifibrinolytics and attenuated androgens. Our case highlights less common gastrointestinal presentation of acquired angioedema and the effectiveness of fresh frozen plasma and icatibant in its treatment. We also reiterate that early diagnosis of acquired angioedema is key for treatment of potentially life-threatening attacks and to initiate prophylaxis for recurrent attacks.2503_A Figure 1. Contrast enhanced CT abdomen showing small bowel wall (jejunal) thickening2503_B Figure 2. Push enteroscopy showing normal small bowel mucosa after resolution of acute angioedema attack

Differentiation of benign and malignant ampullary obstruction by multi-row detector CT.

To determine useful CT parameters to differentiate ampullary carcinomas from benign ampullary obstruction. This study included 93 patients who underwent abdominal CT, 31 patients with ampullary carcinomas, and 62 patients with benign ampullary obstruction. Two radiologists independently evaluated CT parameters then reached consensus decisions. Statistically significant CT parameters were identified through univariate and multivariate analyses. In univariate analysis, the presence of ampullary mass, asymmetric, abrupt narrowing of distal common bile duct (CBD), dilated intrahepatic bile duct (IHD), dilated pancreatic duct (PD), peripancreatic lymphadenopathy, duodenal wall thickening, and delayed enhancement were more frequently in ampullary carcinomas observed (P < 0.05). Multivariate logistic regression analysis using significant CT parameters and clinical data from univariate analysis, and clinical symptom with jaundice (P = 0.005) was an independent predictor of ampullary carcinomas. For multivariate analysis using only significant CT parameters, abrupt narrowing of distal CBD was an independent predictor of ampullary carcinomas (P = 0.019). Among various CT criteria, abrupt narrowing of distal CBD and dilated IHD had highest sensitivity (77.4%) and highest accuracy (90.3%). The abrupt narrowing of distal CBD and dilated IHD is useful for differentiation of ampullary carcinomas from benign entity in patients without the presence of mass.

CT findings of the commonly overlooked groove pancreatitis

PurposeThe aim of this study was to highlight the different computed tomography (CT) features of groove pancreatitis (GP) in order to make this entity more familiar to radiologist. Patients & methodThis study enrolled 15 patients who had histopathologically confirmed GP. Their CT scans were retrospectively reviewed for the encountered manifestations. ResultsPure & segmental forms were identified retrospectively in 6 & 9 patients. The most frequent findings noted in patients' scans were the following, in descending order: medial duodenal wall thickening & cysts, duodenal luminal narrowing, regional lymphadenopathies, pancreatic involvement, isolated groove affection, pancreatic calcifications, distal CBD narrowing, pancreatic duct abnormalities, and retro-peritoneal stranding. ConclusionAlthough the CT features of GP mimic other peripancreatic tumors, yet the constantly associated findings in the proven cases of GP in our study were: duodenal wall thickening, cysts formation, and luminal narrowing. So the presence of these features in alcoholic middle aged male patient with groove or pancreatic lesion, have to trigger radiologist's dubiety of GP entity and so to be addressed in his opinion. Nevertheless, GP diagnosis is still challenging & should be considered based on clinical & radiological data in conjunction with the laboratory and pathological results.

Diffuse Large B-Cell Lymphoma Presenting as a Pancreatic Mass

Primary lymphomas of the gastrointestinal tract are rare; however is the most common site of extranodal involvement. When presenting as a primary lesion, a distinction from an epithelial malignancy is critical given the difference in therapy and prognosis. Primary pancreatic lymphomas represent cancer. On physical exam, he looked chronically ill, had pale conjunctiva, tenderness to palpation in epigastric area,and palpable inguinal lymphadenopathy. Initial CBC, chemistries and liver function tests were unremarkable. LDH was elevated and CA19-9 level was normal. An abdominal CT revealed a pancreatic tail mass measuring 3.1 x 2.3 cm associated with duodenal wall thickening, peripancreatic, supraclavicular, mediastinal and inguinal lymphadenopathy. Also, a cardiac intraventricular mass that measured 6.3 x 4cm was seen occluding almost all the right ventricle.Important to note is that the liver was unremarkable. A PET CT scan showed multiple FDG-avid lesions including the pancreatic tail and cardiac masses, with a foci of highest tracer uptake near the duodenum. An ultrasound guided biopsy of a neck nodule for immunohistochemistry showed large cells with vesicular nuclei and prominent nucleoli; the cells stained positive for CD20, CD45, suggesting diffuse large B-cell lymphoma (DLBCL). He received rituximab,cyclophosphamide, doxorubicin, vincristine, prednisone, and entecavir.Figure: Pancreatic tail mass approximately 3.1 x 2.3cm.Figure: There is a foci of severe high tracer uptake of the pancreas.Figure: Multiple hypermetabolic lesions are evident.After completion of first course, he was discharged home. While at home he developed gastrointestinal bleeding that required hospitalization. At that time and while his performance status declined, he refused further treatment. This case shows that a distinction between DLBCL and pancreatic adenocarcinoma is challenging but extremely important since treatment and prognosis are very different. This patient presented with abdominal symptoms and radiologic evidence of a pancreatic mass with regional and distant lymphadenopathy initially suggesting a primary pancreatic neoplasm. However, the absence of liver metastases, B symptoms, cardiac involvement and the extensive lymphadenopathy suggested a lymphoproliferative disease. The early suspicion of this rare presentation of Non-Hodgkin's lymphoma involving the pancreas, duodenum and right ventricle helped establish timely and appropriate therapy given the high mortality associated with this disease.

Use of Infliximab for the Treatment of Sweetʼs Syndrome in a Patient with Inflammatory Bowel Disease

INTRODUCTION: Sweet's Syndrome is characterized by fever, neutrophilia, painful erythematous skin lesions (papules, nodules, plaques) and a diffuse neutrophilic infiltrate in the upper dermis of the skin. It can be idiopathic, malignancy-associated or drug-induced. CASE REPORT: A 47 year old female with Ulcerative Colitis presented with 3 days of nausea, vomiting and diarrhea. She was receiving Azathioprine 100mg daily for 3 years. Laboratory studies were significant for WBC 18.4 (89% neutrophils), ESR 20, CRP 14. Stool cultures and clostridium difficile toxin were negative. CT scan showed diffuse colonic, gastric antral and duodenal wall thickening. Upper endoscopy revealed diffuse gastric erythema, and shallow duodenal ulcerations (pathology showing acute and chronic duodenitis). Flexible sigmoidoscopy showed confluent ulcerations and mucus exudates in the recto-sigmoid colon (pathology showing chronic active colitis). 3 days after admission, she developed high grade fevers (1020 F), and new erythematous tender papules on the torso and extremities. Biopsy of the papules showed interstitial neutrophilic infiltrate in the upper dermis consistent with Sweet's Syndrome. She declined steroid therapy due to a prior adverse reaction of elevated intraocular pressures, but agreed to treatment with Infliximab at a dose of 5mg/kg. Her skin lesions and fever resolved within 2 days, and she had improvement of her gastrointestinal complaints. She was discharged, continued on outpatient Infliximab therapy and is currently in clinical remission. DISCUSSION: We report a case of Sweet's Syndrome in a patient with inflammatory bowel disease (IBD) successfully treated with Infliximab. Sweet's Syndrome is a rare extra-intestinal manifestation of IBD, presenting independent of its activity and should be considered in the differential diagnosis of a patient with IBD who develops skin lesions. The skin manifestations can last for weeks to months without treatment. Systemic corticosteroids are the gold standard therapy. The success of Infliximab in our patient's treatment supports the role of tumor necrosis factor (TNF) in the pathogenesis of Sweet's Syndrome. Few case reports have shown the treatment of Sweet's Syndrome associated with IBD with infliximab at doses of 5mg/kg and 10mg/kg. Our case suggests that Infliximab and other anti-TNF agents can be successfully used as a second line therapy for Sweet's Syndrome in those with IBD.Figure 1Figure 2

Groove pancreatitis: Imaging features and management

The aim of this retrospective study was to highlight the imaging findings of groove pancreatitis (GP) as well as its management. Patients and methods16 patients diagnosed to have GP were enrolled in this work. The included patients had complete records of the thorough clinical examination and laboratory workup. All patients had been examined by multi-phase contrast enhanced MDCT tailored for pancreatic imaging. Six of these patients were additionally examined by MRI including MRCP., ResultsMDCT Multiple detector computed tomography of the 16 patients revealedthe following: (1) a hypodense sheet in the pancreaticoduodenal (PD) groove seen in 12 patients with mild enhancement in the delayed phase seen in 6 of the them; (2) Duodenal wall thickening was seen in 10 patients while (3) associated cysts within the duodenal wall or in PD groove were seen in 6 patients; (4) and pancreatic head enlargement in 8 patients. MRI of Six patients revealedthe following: (1) a T1 hypointense and T2 iso to hyperintense sheet at the PD groove in 4 patients with delayed enhancement in 3 of them; (2) Duodenal wall thickening with T2 high signal was seen in 6 patients while associated cysts within the duodenal wall were seen in 4 patients; (3) Pancreatic head enlargement seen in 4 patients; The MRCP of these patients showed dilated CBD with distal tapering and a distance separating its end from the duodenal wall. ConclusionGP is a disease that should be considered in the list of differential diagnosis of masses implicating the pancreatic head and medial duodenal wall. Imaging findings that are suggestive of GP include chronic inflammatory changes with fibrosis in the PD groove with or without implication of the nearby head of the pancreas, duodenal medial mural thickening with luminal stenosis and cysts at the PD groove or within the duodenal wall. Vascular invasion is a sign against diagnosis of GP.

Synchronous double primary renal cell carcinoma and duodenal adenocarcinoma

As a result of development in medical diagnostic technology, the incidence of double primary cancer is increasing. In case that one primary cancer was identified by pathologic finding and has suggestive multiple metastatic lesions of the cancer, it is often difficult that the lesions are considered as another synchronous primary malignancy, not as metastasis of primary cancer. Here, we report a rare case of synchronous double primary renal cell carcinoma that was diagnosed initially as metastatic duodenal adenocarcinoma. A 66-year-old man presented with a palpable abdominal mass. Abdominal computed tomography showed duodenal wall thickening and hypervascular masses in the liver and left kidney. Esophagogastroduodenoscopy revealed an ulcerative lesion in the duodenal bulb, and endoscopic biopsy identified moderately-differentiated adenocarcinoma. We regarded the findings as duodenal adenocarcinoma with metastasis to liver and kidney. So he was treated with fluoropyrimidine-based chemotherapy for the diagnosis of duodenal adenocarcinoma with liver and renal metastases. After 10 months, he developed a right forearm mass. Morphological and immunohistochemical analysis of an incisional biopsy of the forearm mass were consistent with a diagnosis of metastatic renal cell carcinoma. Even when there is a pathologically confirmed malignancy, clinicians must consider the possibility of synchronous double primary malignancy in metastatic lesions.

Multidetector CT imaging of the pancreatic groove: differentiating carcinomas from paraduodenal pancreatitis

ObjectiveThis study aims to identify multidetector row CT (MDCT) findings that differentiate paraduodenal pancreatitis (PDP) from groove carcinomas (GC). MethodsTwo radiologists retrospectively reviewed various imaging features on pancreas protocol CT scans of 8 PDP and 8 GC patients. Two-tailed Fisher's Exact Test was used for statistical analysis. ResultsMDCT findings correlating with PDP included benign common bile duct morphology (P<.01), duodenal wall thickening (P<.05), and cystic groove lesions (P<.01). A statistical difference in gastroduodenal artery (GDA) encasement was not observed (P=.119). ConclusionsThere are several MDCT findings that favor PDP over GC. However, presence of GDA encasement is not a reliable distinguishing feature.

The evaluation of abdominal findings in Crimean-Congo hemorrhagic fever.

Crimean-Congo hemorrhagic fever (CCHF) is a widely seen, fatal disease and is endemic to some countries. It affects many organs in the abdomen. Comprehensive radiological study of CCHF is quite rare. This study will use multiple detector computed tomography (MDCT) to investigate if there is a relationship between clinical laboratory measurements and abdominal findings in CCHF and discuss our findings in the light of the literature. We retrospectively evaluated the medical records of 443 patients diagnosed with CCHF in our hospital between April 1, 2008 and September 30, 2014. Fifty-one patients had undergone abdominal MDCT examination. The most common findings seen in abdominal MDCT were intra-abdominal free fluid and hepatomegaly. Gallbladder wall thickening, heterogeneity in mesenteric, omental fatty tissue, and splenomegaly were other common findings. Subcutaneous fat tissue edema, intramuscular hemorrhage, duodenal wall thickening, colon wall thickening, pancreatitis, and acute renal failure were among the rare findings seen in abdominal MDCT. Comparison of these findings to the clinical laboratory parameters showed a strong relationship between intra-abdominal free fluid and platelet count. Our study is the first comprehensive study on abdominal MDCT findings of CCHF. We detected a strong relationship between patients' platelet count and abdominal free liquid. Therefore, it should be kept in mind that abdominal free fluid can be among clinical manifestations in patients with platelet counts ≤50000 and that this manifestation can become aggravated.

A Not-So-Groovy Masquerader: A Case Report of Groove Pancreatitis

Background: Groove pancreatitis is an uncommon and under-recognized form of focal chronic pancreatitis of the area between the pancreatic head and duodenum due to obstruction of pancreatic juice flow in the minor duct. This disease entity creates a diagnostic challenge as clinical, radiographic, and gross pathologic features can mimic pancreatic adenocarcinoma. Case: A 54-year-old male former-smoker with a history of chronic alcohol consumption presented initially with refractory pyrosis and nausea. Esophagogastroduodenoscopy (EGD) demonstrated duodenal wall thickening and a CT scan of his abdomen revealed duodenitis and inflammation of the pancreatic head with fat stranding. He re-presented three years later with worsening epigastric pain and a 60 pound weight loss. Repeat CT scan revealed an infiltrating heterogeneously enhancing process between the descending duodenum and pancreatic head (Figure 1). Magnetic resonance cholangiopancreatography (MRCP) revealed a 2.7 x 2.3 x 2.3cm mass with soft tissue infiltration and narrowing of the distal common bile duct (CBD) concerning for possible malignancy. CA 19-9 and liver function tests were within normal limits. Continued abdominal pain, intolerance to oral intake, persistent nausea and vomiting, and continued weight loss lead to endoscopic ultrasound (EUS). This demonstrated diffuse pancreatic head and genu parenchymal abnormalities, a 10mm CBD, and enlarged peripancreatic lymph nodes. Repeat MRCP on subsequent admission again revealed focal groove-centric changes of acute and chronic pancreatitis with duodenal wall thickening. EGD/EUS with duodenal biopsies demonstrated focal duodenitis with prominent Brunner glands and fine needle aspiration of the mass revealed cellular atypia and chronic inflammation consistent with chronic pancreatitis and a diagnosis of groove pancreatitis was established.Figure 1Discussion: Groove pancreatitis poses a diagnostic challenge due to its malignancy-like presentation and clinical course. Many of the described risk factors and classical findings of groove pancreatitis were present in our patient including chronic tobacco and alcohol use, severe weight loss secondary to duodenal stenosis, sheet-like mass lesion in the periduodenal space, and prolonged time to diagnosis. However, his clinical course demonstrates the complex nature of this disease process, the close resemblance to pancreatic malignancy, and the difficulty in differentiating these two conditions to arrive at a diagnosis.

Cystic form of paraduodenal pancreatitis (cystic dystrophy in heterotopic pancreas (CDHP)): a potential link with minor papilla abnormalities? A study in a large series.

To analyze the association between cystic dystrophy in the heterotopic pancreas (CDHP) and minor papilla abnormalities. Seventy-six patients with CDHP were retrospectively included over 14 years. Two radiologists searched for MDCT signs of CDHP (cysts and thickened intestinal wall, inflammatory changes), and minor papilla abnormalities (Santorini duct dilatation, luminal calcifications of the minor papilla). Other pancreatic abnormalities (parenchymal calcifications, main pancreatic duct dilatation) or bile duct dilatation were also analysed. CDHP was mostly located in the second part of the duodenum (71/76, 93.5 %). Median duodenal wall thickness was 20 mm (range 10-46). There were multiple cysts in 86 % (65/76, median = 3), measuring 2-60 mm. No cysts were identified in four patients (5 %). Inflammatory changes were found in 87 % (66/76). Minor papilla abnormalities were found in 37 % (28/76) and calcifications in the minor papilla without calcifications in the major papilla were only observed in three patients (4 %). Abnormalities of the pancreas and main bile duct dilatation were identified in 78 % (59/76) and 38 % (29/76). Previously described CT features were seen in most patients with CDHP. However, minor papilla abnormalities were seen in a minority of patients and, therefore, do not seem to be a predisposing factor for CDHP. Imaging features suggesting a CDHP diagnosis are confirmed in a large series. Minor papilla abnormalities do not seem to be a predisposing factor for CDHP. Most patients did not have any isolated minor papilla abnormalities.

Faecal calprotectin levels in children with Henoch-Schönlein purpura: is this a new marker for gastrointestinal involvement?

We aimed to investigate the significance of faecal calprotectin (FC) levels in children diagnosed with Henoch-Schönlein purpura (HSP) and examine its relationships with gastrointestinal system (GIS), renal involvement and with clinical findings. In total, 66 children diagnosed with HSP for the first time and a control group of 25 healthy children were included. The cases were divided into mild and severe groups on the basis of GIS findings. FC was measured twice in all patients with HSP: within 3 days of onset of disease (FC1) and on day 15 (FC2). These results were compared with those of the control group. Faecal occult blood, gastric wall thickness and duodenal wall thickness were measured at the same time as FC1 in all patients, and the presence of renal involvement was recorded. Of the 66 patients, 37 (56%) were females (mean age, 7.5±2.9 years; range, 2.5-14.5 years) and were diagnosed with HSP. Renal involvement was detected in 19 (28%) cases and GIS involvement was found in 28 (43%) cases. GIS involvement was mild in 16 (53%) cases and severe in 12 (43%). A significant difference was detected in FC1 levels between the groups with and without GIS involvement (P=0.01). A marked difference was observed in FC1 levels between the groups with and without renal involvement (P=0.017). FC may be a reliable marker for HSP, particularly for identifying GIS and renal involvement as well as disease severity.

Acute abdomen due to complicated intramural duodenal haematoma. Case report and literature review

Abstract Background Intramural duodenal haematoma is a rare entity that usually occurs in the context of patients with coagulation disorders. A minimum percentage is related to processes such as pancreatitis and pancreatic tumours. Clinical case The case is presented of a 45 year-old male with a history of chronic pancreatitis secondary to alcoholism. He was seen in the emergency room due to abdominal pain, accompanied by toxic syndrome. The abdominal computed tomography reported increased concentric duodenal wall thickness, in the second and third portion. After oesophageal-gastro-duodenoscopy, he presented with haemorrhagic shock. He had emergency surgery, finding a hemoperitoneum, duodenopancreatic tumour with intense inflammatory component, as well a small bowel perforation of third duodenal portion. A cephalic duodenopancreatectomy was performed with pyloric preservation and reconstruction with Roux-Y. Discussion Treatment of a duodenal haematoma is nasogastric decompression, blood transfusion and correction of coagulation abnormalities. Surgery is indicated in the cases in which there is no improvement after 2 weeks of treatment, or there is suspicion of malignancy or major complications arise. Conclusions Duodenal intramural haematoma secondary to chronic pancreatitis is rare, although the diagnosis should be made with imaging and, if suspected, start conservative treatment and surgery only in complicated cases.