Focal Pancreatitis Research Articles

Focal Pancreatitis Mimicking Neuroendocrine Tumor on DOTATATE PET/CT With Radiology-Pathology Correlation.

A 54-year-old man presented with left lower quadrant pain. CT showed no cause for his pain but identified an incidental 2.0-cm enhancing lesion in the pancreatic tail. On MRI, this lesion was hyperenhancing and diffusion-restricting, suspicious for a neuroendocrine tumor. However, EUS-guided biopsy yielded only benign pancreatic tissue. Due to this discordance, 64 Cu-DOTATATE PET/CT was performed. The pancreatic tail lesion was tracer-avid, suggesting a well-differentiated neuroendocrine tumor. Based on the PET findings, the patient underwent distal pancreatectomy. Surgical pathology revealed only focal chronic pancreatitis with islet aggregation, a previously undescribed mimic of neuroendocrine tumor on DOTATATE PET/CT.

Using Fuzzy Mathematical Model in the Differential Diagnosis of Pancreatic Lesions Using Ultrasonography and Echographic Texture Analysis.

Malignant tumors of the pancreas are the fourth leading cause of cancer-related deaths. This is mainly because they are often diagnosed at a late stage. One of the challenges in diagnosing focal lesions in the pancreas is the difficulty in distinguishing them from other conditions due to the unique location and anatomy of the organ, as well as the similarity in their ultrasound characteristics. One of the most sensitive imaging modalities of the pancreas is endoscopic ultrasonography. However, clinicians recognize that EUS is a difficult and highly operator-dependent method, while its results are highly dependent on the experience of the investigator. Hybrid technologies based on artificial intelligence methods can improve the accuracy and objectify the results of endosonographic diagnostics. Endoscopic ultrasonography was performed on 272 patients with focal lesions of the pancreatobiliary zone, who had been treated in the surgical section of the Kursk Regional Clinical Hospital in 2014-2023. The study utilized an Olympus EVIS EXERA II video information endoscopic system, along with an EU-ME1 ultrasound unit equipped with GF UM160 and GF UC140P-AL5 echo endoscopes. Out of the focal formations in the pancreatobiliary zone, pancreatic cancer was detected in 109 patients, accounting for 40.1% of the cases. Additionally, 40 patients (14.7%) were diagnosed with local forms of chronic pancreatitis. The reference sonograms displayed distinguishable focal pancreatic pathologies, leading to the development of hybrid fuzzy mathematical decision-making rules at the South-West State University in Kursk, Russian Federation. This research resulted in the creation of a fuzzy hybrid model for the differential diagnosis of chronic focal pancreatitis and pancreatic cancer. Endoscopic ultrasonography, combined with hybrid fuzzy logic methodology, has made it possible to create a model for differentiating between chronic focal pancreatitis and pancreatic ductal adenocarcinoma. Statistical testing on control samples has shown that the diagnostic model, based on reference endosonograms of the echographic texture of pancreatic focal pathology, has a confidence level of 0.6 for the desired diagnosis. By incorporating additional information about the contours of focal formations obtained through endosonography, the reliability of the diagnosis can be increased to 0.9. This level of reliability is considered acceptable in clinical practice and allows for the use of the developed model, even with data that is not well-structured.

The clinical characteristics of focal acute pancreatitis based on imaging diagnosis: comparison with non-localized acute pancreatitis- a preliminary result

BackgroundFocal acute pancreatitis is a special type of acute pancreatitis, which diagnosis is based on image showing a focal mass formation in the pancreas. For acute pancreatitis with or without focal inflammatory enlargement, little is known on differences between them. Our purpose was to find differences between focal acute pancreatitis and non-localized acute pancreatitis.MethodsWe reviewed the medical records of a total of 24 patients diagnosed with focal acute pancreatitis by imaging and clinical diagnosis, and 27 cases of acute pancreatitis which manifest non-localized pancreas inflammation were selected as the control group. The differences of the two groups were compared to describe their clinical characteristics.ResultsDifferences in bloating (4.2% VS 29.6%,P = 0.026), abdominal tenderness (58.3% VS 85.2%,P = 0.032), peripheral blood neutrophil ratio (60.1 ± 23.3VS 75.9 ± 12.6,P = 0.004), serum D-Dimer (0.40(0.25,0.98) VS 1.59(0.49,4.63),P = 0.008), serum GGT (40(25,91) VS120(22,383),P = 0.046), serum amylase(435(241,718) VS 591(394,1333),P = 0.044) and lipase(988(648,1067) VS 1686(525,2675),P = 0.027) between focal acute pancreatitis and non-localized acute pancreatitis groups were statistically significant. However, difference of the severity of two groups was not statistically significant (P = 1.000).ConclusionCompared with non-localized acute pancreatitis, changes in symptoms, signs and laboratory indicators of focal acute pancreatitis are non-obvious, however, there was no significant difference in the severity of two groups, indicating that we should pay more attention to diagnosis of focal acute pancreatitis in clinical practice.

Multiparameter diagnostic model based on 18F-FDG positron emission tomography and serological examination for differentiating focal autoimmune pancreatitis from pancreatic ductal adenocarcinoma.

18F-fluorodeoxyglucose positron emission tomography-computerized tomography (18F-FDG PET-CT) has demonstrated high sensitivity in the diagnosis of autoimmune pancreatitis (AIP) and pancreatic ductal adenocarcinoma (PDAC), while also exhibiting the ability to distinguish AIP from PDAC lesions. The objective of this investigation was to assess the efficacy of multiparametric 18F-FDG PET with serological examination for distinguishing focal AIP (f-AIP) from PDAC. A total of 127 patients (43 with f-AIP and 84 with PDAC) who received 18F-FDG PET-CT before treatment were retrospectively included in the cohort study conducted at two centers, Beijing Friendship Hospital and Chinese PLA General Hospital, from January 2015 to December 2021. The baseline characteristics and clinical data were collected. The metabolism parameters of 18F-FDG PET, including maximum standardized uptake value (SUVmax), tumor-to-normal liver SUV ratio (SUVR), mean SUV (SUVmean), total lesion glycolysis (TLG), and metabolic tumor volume (MTV) were evaluated. The area under the receiver operating characteristic (ROC) curve was used to evaluate the differential diagnostic efficacy. The diagnostic efficacy improvement was assessed through the integrated discriminatory improvement (IDI), net reclassification improvement (NRI), and DeLong test. Serum immunoglobulin G4 (IgG4) >280 mg/dL, carbohydrate antigen 19-9 (CA19-9) <85 U/mL, and metabolic parameters differed significantly between patients with f-AID and PDAC. The ROC curve analysis of MTV showed the highest differentiating diagnostic value [sensitivity =0.814, 95% confidence interval (CI): 0.661-0.911; specificity =0.893, 95% CI: 0.802-0.947; area under the curve (AUC) =0.890, 95% CI: 0.820-0.957]. The combined diagnostics model of serum IgG4 >280 mg/dL, CA19-9 <85 U/mL, and MTV resulted in the highest AUC of 0.991 (95% CI: 0.978-1.000; sensitivity =0.953, 95% CI: 0.829-0.992; specificity =0.964, 95% CI: 0.892-0.991). The multiparameter diagnostic model based on 18F-FDG PET and serological examination has excellent clinical value in the differential diagnosis of f-AID and PDAC.

Duodenum-preserving pancreatic head resection or pancreatoduodenectomy for the surgical treatment of paraduodenal pancreatitis: a retrospective cohort study

Paraduodenal pancreatitis (PDP) is an uncommon yet well-described type of focal chronic pancreatitis. The aim of our study was to compare the outcomes of surgical treatment of patients with PDP using pancreatoduodenectomy and duodenum-preserving pancreatic head resection (DPPHR). A retrospective analysis of 153 consecutive patients with PDP was performed. Patients who were treated with either DPPHR or PD were enrolled. The primary endpoint of the study was pain control achieved at the time of follow-up. The secondary endpoints of the study were complication rate (Clavien-Dindo > 2), hospital length of stay, and 90-day mortality. All patients were followed up after discharge for the assessment of pain cessation for a minimal period of 10 months. The final study population consisted of 71 patients. A total of 14 patients (19.7%) underwent pancreatoduodenectomy, and 57 (80.3%) were managed with DPPHR. Complication rate was significantly lower in DPPHR group at χ2 = 4.2677, p < 0.05. Mean hospital length of stay was 9.3 days (range 3-29) in DPPHR group and 13.9 days (range 7-35) in PD group (p < 0.05). No postoperative mortality was recorded. The mean follow-up period of the patients after surgery was 41.8 ± 20.6 months (range 10-88). Pain scores at the time of operation were calculated as 50.9 ± 12.1 in DPPHR group and 56.1 ± 11.4 in PD group. At the time of follow-up, pain scores improved significantly in both groups and were 10.3 ± 8.8 and 10.9 ± 8.6, respectively. DPPHR achieves similar results in pain control as PD with a lower complication rate and shorter hospital LOS.

Differential Diagnosis of Metastatic Lesions in the Pancreas in Patients with Renal Cell Carcinoma and Focal Chronic Pancreatitis: A Clinical Observation

Представлено наблюдение 62-летней больной с метастатическим поражением поджелудочной железы почечно-клеточным раком спустя 15 лет после радикальной нефрэктомии справа. Заболевание успешно диагностировано безоперационным путем: выполнена тонкоигольная пункционная биопсия с последующим иммуногистохимическим исследованием препарата, таким образом диагноз был верифицирован и исключен очаговый хронический панкреатит. Пациентке проведена лекарственная противоопухолевая терапия, которую она перенесла хорошо, достигнут частичный ответ.&#x0D; &#x0D; Ключевые слова: почечноклеточный рак, почечноклеточная карцинома, очаговый панкреатит, карцинома поджелудочной железы, псевдокиста головки поджелудочной железы, иммуногистохимическое исследование.&#x0D; Авторы подтверждают отсутствие конфликтов интересов.

Diagnostic value of homogenous delayed enhancement in contrast-enhanced computed tomography images and endoscopic ultrasound-guided tissue acquisition for patients with focal autoimmune pancreatitis.

We aimed to investigate (1) promising clinical findings for the recognition of focal type autoimmune pancreatitis (FAIP) and (2) the impact of endoscopic ultrasound (EUS)-guided tissue acquisition (EUS-TA) on the diagnosis of FAIP. Twenty-three patients with FAIP were involved in this study, and 44 patients with resected pancreatic ductal adenocarcinoma (PDAC) were included in the control group. (1) Multivariate analysis revealed that homogeneous delayed enhancement on contrast-enhanced computed tomography was a significant factor indicative of FAIP compared to PDAC (90% vs. 7%, p=0.015). (2) For 13 of 17 FAIP patients (76.5%) who underwent EUS-TA, EUS-TA aided the diagnostic confirmation of AIPs, and only one patient (5.9%) was found to have AIP after surgery. On the other hand, of the six patients who did not undergo EUS-TA, three (50.0%) underwent surgery for pancreatic lesions. Homogeneous delayed enhancement on contrast-enhanced computed tomography was the most useful clinical factor for discriminating FAIPs from PDACs. EUS-TA is mandatory for diagnostic confirmation of FAIP lesions and can contribute to a reduction in the rate of unnecessary surgery for patients with FAIP.

Pancreaticoduodenectomy for severe duodenal stenosis and biliary-duodenal fistula induced by groove pancreatitis due to repetitive duodenal ulcers: A pediatric case report

Groove pancreatitis (GP), an uncommon form of recurrent or chronic focal pancreatitis, is exceedingly rare in children. This report describes a case of pancreaticoduodenectomy performed for severe duodenal stenosis and biliary-duodenal fistula induced by GP in a child. A 14-year-old boy presented to a gastroenterologist due to repeated abdominal pain for 5 years. Esophagogastroduodenoscopy, computed tomography, and magnetic resonance cholangiopancreatography suggested a duodenal ulcer that was possibly associated with GP. The patient was referred to our hospital for further examination. Endoscopic retrograde cholangiopancreatography revealed stenosis of the main pancreatic duct and ectopic opening of the common bile duct into the duodenum (biliary-duodenal fistula). An internal pancreatic stent was placed via the papilla of Vater to treat obstructive pancreatitis, while an internal biliary stent was placed through the fistula to prevent cholangitis. Replacement of the pancreatic stent was deemed impossible due to exacerbation of the duodenal stenosis. Considering the limitations of repeated endoscopic treatment, radical surgical intervention and subtotal stomach-preserving pancreaticoduodenectomy were performed. Relapse of previous abdominal symptoms and surgery-associated long-term complications did not occur postoperatively. In pediatric GP cases without any contributing factors of chronic pancreatitis, such as pancreas divisum, GP is often attributable to repetitive duodenal ulcers.

A292 ACUTE PANCREATITIS AS THE FIRST PRESENTATION OF GRANULOMATOSIS WITH POLYANGIITIS (GPA): A CASE REPORT

Abstract Background Granulomatosis with Polyangiitis (GPA) is a rare necrotizing ANCA-associated vasculitis characterized by inflammation in small-sized arteries. GPA often presents with a triad of a) upper (nasal obstruction, sinusitis, crusting rhinitis) and lower respiratory tract (lung nodules, alveolar hemorrhage) b) systemic vasculitis and c) kidney involvement (necrotizing glomerulonephritis). However, gastrointestinal involvement is exceedingly rare and only occurs in about 5-11% of GPA cases. Specifically, recurrent acute pancreatitis is even more uncommon. Purpose To raise awareness about systemic vasculitides in cases of idiopathic acute pancreatitis Method A 48-year-old female was seen in an outpatient gastroenterology clinic for recurrent idiopathic pancreatitis. She reported a six-month history of intermittent sharp epigastric pain associated with a rise in lipase. The patient noted having episodes of acute sinusitis shortly prior to the onset of her epigastric pain. Her initial labwork revealed normal creatinine and liver enzymes, elevated total bilirubin 24, lipase 316 and mildly high CRP 16.1 and ESR 27 which normalized on repeat blood work. Abdominal US was unremarkable with no gallstones, intra- or extrahepatic duct dilatation. An abdominal MRI revealed segmental enlargement of the distal tail/body of the pancreas consistent with resolving focal pancreatitis. A follow-up MRI 5 weeks later revealed progression of pancreatic swelling and intermittent narrowing of the pancreatic duct. These findings were suspicious for an inflammatory process such as autoimmune pancreatitis. The patient then underwent EUS-guided examination and FNA of her pancreas. Pathology revealed focal chronic pancreatitis with fibrosis and mild lymphocytic infiltrate, but was not suggestive of autoimmune pancreatitis. She was then treated empirically with a 3-month course of prednisone and had significant improvement in her symptoms and interval resolution of pancreatic inflammation on repeat MRI. After discontinuation of her steroids, her symptoms recurred with intermittent epigastric pain, facial pain and sinusitis. She was then seen by rheumatology and an autoimmune panel was ordered. Result(s) Autoimmune work-up revelead positive anti-PR3 (27 RU/ml), negative anti-MPO and normal IgG-4 levels. Ultimately a diagnosis of limited GPA, which spares the kidneys, was made given the patient’s clinical presentation and positive anti-PR3 antibody. Since there was no life-threatening organ involvement, she was elected to start methotrexate therapy and had significant improvement in her symptoms. The plan is to stay on methotrexate for at least 24 months and have regular follow-up to ensure clinical stability. Conclusion(s) Acute pancreatitis is a rare initial presentation of GPA vasculitis. It is important to consider autoimmune disease and systemic vasculitides in cases of idiopathic pancreatitis after ruling out common causes. Early diagnosis and therapy allow for high rates of remission and improved survival rates. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

Follicular pancreatitis: Case report and literature review.

Follicular pancreatitis is a very rare type of focal chronic pancreatitis and is often mistaken for pancreatic neoplasms. It is histologically characterized by extensive lymphoid follicular formation with reactive germinal centers. A 50-year-old man was admitted to our hospital with 1-month history of epigastric pain. Contrast-enhanced computed tomography and magnetic resonance imaging revealed a 4.7 cm sized enhancing pancreatic head mass with anterior mesenteric soft tissue infiltration and superior mesenteric vein invasion. Endoscopic ultrasonography revealed an ill-defined hypoechoic mass in the head of the pancreas. A laparoscopic surgical biopsy was performed. Hematoxylin-eosin staining showed the acini structure destruction within the pancreatic parenchyma and different-sized lymphoid follicles with reactive germinal centers around the duct. Immunohistochemical examination showed that cells were positive for the B-cell marker CD20, T-cell marker CD3, and slightly positive for IgG4. However, cells were negative for the B-cell marker Bcl-2. Follicular pancreatitis was confirmed based on the findings of histology and immunohistochemistry. The patient was regularly followed without any specific treatment. Follow-up computed tomography revealed no change in the lesion 1 year after diagnosis. To the best of our knowledge, this is the first case of follicular pancreatitis in Korea.

Clinical Features and Computed Tomography Radiomics-Based Model for Predicting Pancreatic Ductal Adenocarcinoma and Focal Mass-Forming Pancreatitis.

Objective: To establish a predictive model distinguishing focal mass-forming pancreatitis (FMFP) from pancreatic ductal adenocarcinoma (PDAC) based on computed tomography (CT) radiomics and clinical data. Methods: A total of 78 FMFP patients (FMFP group) and 120 PDAC patients (PDAC group) who were admitted to Xiangyang No.1 People's Hospital and Xiangyang Central Hospital from February 2012 to May 2021 and were pathologically diagnosed were included in this study, and were input to set up the training set and test set at a ratio of 7:3. The 3Dslicer software was used to extract the radiomic features and radiomic scores (Radscores) of the 2 groups, and the clinical data (age, gender, etc), CT imaging features (lesion location, size, enhancement degree, vascular wrapping, etc) and CT radiomic features of the 2 groups were compared. Logistic regression was used to screen the independent risk factors of the 2 groups, and multiple prediction models (clinical imaging model, radiomics model, and combined model) were established. Then the receiver operating characteristic (ROC) analysis and decision curve analysis (DCA) were conducted to compare the prediction performance and net benefit of the models. Results: The multivariate logistic regression results indicated that dilation of the main pancreatic duct, vascular wrapping, Radscore1 and Radscore2 were independent influencing factors for distinguishing FMFP from PDAC. In the training set, the combined model showed the best predictive performance (area under the ROC curve [AUC] 0.857, 95% CI [0.787-0.910]), significantly higher than the clinical imaging model (AUC 0.650, 95% CI [0.565-0.729]) and the radiomics model (AUC 0.812, 95% CI [0.759-0.890]). DCA confirmed that the combined model had the highest net benefit. These results were further validated by the test set. Conclusion: The combined model based on clinical-CT radiomics data can effectively identify FMFP and PDAC, providing a reference for clinical decision-making.

S1731 Fibrosing Pancreatitis Initially Diagnosed as Ductal Adenocarcinoma by Endoscopic Ultrasound of a Pancreatic Mass in a Pediatric Patient

Introduction: Pancreatic cancer is very rare in the pediatric population. Incidence data is scarce, and few case reports have been published. Pancreatic ductal adenocarcinoma (PDA) is the most common subtype in adults, but is rare in children. We report a case of a benign pancreatic head mass in a pediatric patient initially diagnosed as PDA on endoscopic ultrasound (EUS) guided biopsy. Case Description/Methods: A 13-year-old male with past medical history of treated Helicobacter pylori infection 6 months prior was admitted for severe acute intermittent epigastric pain. Labs showed elevated transaminases and gamma-glutamyl transferase. Abdominal ultrasound demonstrated an indeterminate solid mass-like lesion of 3 cm at the pancreatic head, and the common bile duct (CBD) was dilated to 0.9 cm. Magnetic resonance cholangiopancreatography showed a 2.2 cm indeterminate lesion along the pancreatic head region with dilated CBD of 1.4 cm, tapering at the level of the lesion. On hospital day 3, the patient underwent esophagogastroduodenoscopy and EUS. A parenchymal mass of 2.2 cm was visualized in the head of pancreas, and fine needle biopsy was performed. Cytology diagnosis was well differentiated ductal adenocarcinoma. Serum carcinoembryonic antigen, carbohydrate antigen 19-9, and alpha-fetoprotein were all normal. The patient underwent elective Whipple procedure. Surprisingly, no malignancy was identified on the surgical specimen. Instead the findings supported a diagnosis of localized fibrosing pancreatitis with high background of immunoglobulin G4 with interlobular pattern. Patient was discharged home on post-operation day 13. EUS cytology was reviewed at a tertiary cancer center and later reported as acute on chronic inflammation without malignancy (Figure). Discussion: Despite increased use of EUS for diagnosis of pancreatic masses, 5-10% of patients who undergo Whipple procedure for presumed malignancy will have benign pathology: most commonly chronic fibrosing pancreatitis, chronic pancreatitis, or focal active pancreatitis. The false positive rate for diagnosing malignancy using EUS-fine needle aspiration (FNA) of solid pancreatic lesions is less than 1%. However, it may be higher in pediatrics as the prevalence of PDA is much lower in adults. For suspected cases of PDA in pediatric patients, additional review of EUS cytology at an experienced and dedicated cancer institution is advisable before further intervention to prevent the medical and psychosocial ramifications of a false positive cancer diagnosis.Figure 1.: (Left) A parenchymal mass (2.2 x 1.8 cm) in the head of the pancreas by endoscopic ultrasound (EUS) adjacent to the portal confluence, with the common bile duct dilated to 12.8 mm (marked by yellow cross signs). Initial cytopathology from EUS-FNA of pancreatic head mass A. Diff-Quik staining at low magnification, 4x. B. Smear is cellular and well preserved with sheets, clusters and single malignant cells, 10x. C. Cells have crowded nuclei, 20x. D. Malignant cells exhibit loss of polarity, irregular nuclear contours, finely granular chromatin and some with prominent nucleoli, 40x . Based on cytomorphological features, the mass is a well differentiated ductal adenocarcinoma of pancreatic head. Note: The review of this cytopathology by a tertiary cancer institution was inconsistent with malignancy. The glandular cells had mild cytologic atypia, and the acinar cells remained lobular in configuration. Although there was some higher nuclear to cytoplasmic ratio, no absolute nuclear enlargement was noticed.

Radiomics and Its Applications and Progress in Pancreatitis: A Current State of the Art Review

Radiomics involves high-throughput extraction and analysis of quantitative information from medical images. Since it was proposed in 2012, there are some publications on the application of radiomics for (1) predicting recurrent acute pancreatitis (RAP), clinical severity of acute pancreatitis (AP), and extrapancreatic necrosis in AP; (2) differentiating mass-forming chronic pancreatitis (MFCP) from pancreatic ductal adenocarcinoma (PDAC), focal autoimmune pancreatitis (AIP) from PDAC, and functional abdominal pain (functional gastrointestinal diseases) from RAP and chronic pancreatitis (CP); and (3) identifying CP and normal pancreas, and CP risk factors and complications. In this review, we aim to systematically summarize the applications and progress of radiomics in pancreatitis and it associated situations, so as to provide reference for related research.

P385 SYNCOPAL VENTRICULAR TACHYCARDIA IN HEALTHY HEART: AN UNUSUAL ORIGIN!

Abstract Torsade de pointes is a particular type of ventricular tachycardia, characterized by QRS complexes that vary progressively in amplitude and morphology, giving the impression of oscillating around the isoelectric line. Causes include long QT syndrome (congenital or drug–induced) or severe hypomagnesemia. We report the case of a 57–year–old woman, a smoker, with a history of weight loss in the last 6 months, hospitalized in Medicine for marked asthenia and an episode of fleeting loss of consciousness, from sitting. She was asymptomatic for chest pain. The physical examination showed a pathological thinness, with BMI 15 kg/m2, rhythmic cardiac activity, no murmurs, no signs of decompensation, flat abdomen, not enlarged liver. Pale, dry skin was observed. On ECG: sinus rhythm, HR 70 bpm, QTc slightly increased 0.47 sec, flat T wave in lateral. Blood exams evidenced: hypokalemia, hypomagnesemia, rise of the amylase. On the MRI abdomen we found large inhomogeneous areas on the head and body of the pancreas, referable to the picture of focal pancreatitis. For syncopal episode during hospitalization in Medicine, she was transferred in Cardiology, where, during electrocardiographic monitoring, paroxysmal ventricular tachycardias torsade de pointes–like, symptomatic, self–resolved was registered. We diagnosed an acute pancreatitis with typical radiological characteristics of an autoimmune form, determining severe electrolyte imbalance and consequent symptomatic paroxysmal ventricular tachycardias. Oral magnesium supplement and corticosteroid therapy allowed the resolution of the arrhythmic problem, monitored over time through the implantation of a loop recorder.

An incidental finding behind adrenal incidentaloma.

SummaryA 61-year-old man went to the Emergency Department with left upper abdominal quadrant pain and low-grade fever, as well as a loss of weight (3 kg in 6 weeks). A solid-cystic lesion in the left adrenal lodge was discovered by abdominal ultrasonography. A slight increase in the serum amylase with normal lipase was observed, but there were no signs or symptoms of pancreatitis. A contrast-enhanced CT revealed a tumor that was suspected of adrenocortical cancer. Therefore, he was referred to the endocrine unit. The hormonal evaluation revealed no signs of excessive or inadequate adrenal secretion. To characterize the mass, an MRI was performed; the lesion showed an inhomogeneous fluid collection with peripheral wall contrast-enhancement, as well as a minor 18-fluorodeoxyglucose uptake at PET/CT images. The risk of primary adrenal cancer was minimal after the multidisciplinary discussion. An acute necrotic collection after focal pancreatitis was suspected, according to the characteristics of imaging. Both CT-guided drainage of the necrotic accumulation and laboratory analysis of the aspirated fluid confirmed the diagnosis.Learning pointsDifferent types of expansive processes can mimic adrenal incidentalomas.Necrotic collection after acute focal pancreatitis could be misdiagnosed as an adrenal mass, since its CT characteristics could be equivocal.MRI has stronger capacities than CT in differentiating complex lesions of the adrenal lodge.A multidisciplinary approach is fundamental in the management of patients with a newly discovered adrenal incidentaloma and equivocal/suspicious imaging features (low lipid content and size >4 cm).

Differential EUS findings in focal type 1 autoimmune pancreatitis and pancreatic cancer: A proof-of-concept study.

ABSTRACTBackground and Objectives:Autoimmune pancreatitis (AIP) often mimics pancreatic cancer (PC), particularly if presenting as a focal lesion. EUS may orient the differential diagnosis between them. This study aims to identify EUS findings that might be useful to differentiate type 1 focal autoimmune pancreatitis (f-AIP1) and PC.Materials and Methods:F-AIP1 and PC patients were retrospectively collected, matched, and compared. EUS findings considered were: focal mass echogenicity, loss of lobularity, distal atrophy, peripancreatic hypoechoic margins (PHM), pancreatic duct dilation, duct-penetrating sign (DPS), pancreatic/common bile duct thickened walls (PD/CBD-TW), and vessel infiltration (VI). Elastography findings were also recorded. Variables with a P < 0.05 at univariate analysis were included in logistic multiple regression.Results:Fifteen patients with f-AIP and 60 with PC were studied. FE was hypoechoic in all patients from both groups. PHM was observed in 40% of f-AIP1 cases but not in PC ones (P < 0.001). DPS was found in 10/15 (66.7%) f-AIP1 and in 7/60 (11.7%) PC patients (P < 0.001). PD-TW and CBD-TW were observed in 66.7%/60% f-AIP1 cases and in 6.7%/13.6% PC patients, respectively (P < 0.001 for both comparisons). Pancreatic masses were significantly different at EUS elastography (elastic respectively in 71.4% f-AIP1 and 3.8% PC, P < 0.001). VI was suspected in 20% of f-AIPs and 85% of PCs (P < 0.001). At multiple regression, PD-TW, CBD-TW, elastic pattern, and the absence of VI independently supported a diagnosis of f-AIP1.Conclusions:Our results suggest that EUS findings deserve consideration in the diagnostic workup of AIP to improve the differential diagnosis with PC.

Duodenum-Preserving Pancreatic Head Resection or Pancreatoduodenectomy for the Surgical Treatment of Paraduodenal Pancreatitis: A Retrospective Cohort Study

Introduction: Paraduodenal pancreatitis (PDP) is an uncommon yet well-described type of focal chronic pancreatitis. The aim of our study was to compare the outcomes of surgical treatment of patients with PDP using pancreatoduodenectomy (PD) and duodenum-preserving pancreatic head resection (DPPHR).

The CEL-HYB1 Hybrid Allele Promotes Digestive Enzyme Misfolding and Pancreatitis in Mice.

Background & AimsA hybrid allele that originated from homologous recombination between CEL and its pseudogene (CELP), CEL-HYB1 increases the risk of chronic pancreatitis (CP). Although suggested to cause digestive enzyme misfolding, definitive in vivo evidence for this postulate has been lacking.MethodsCRISPR-Cas9 was used to generate humanized mice harboring the CEL-HYB1 allele on a C57BL/6J background. Humanized CEL mice and C57BL/6J mice were used as controls. Pancreata were collected and analyzed by histology, immunohistochemistry, immunoblotting, and transcriptomics. Isolated pancreatic acini were cultured in vitro to measure the secretion and aggregation of CEL-HYB1 protein. Mice were given caerulein injections to induce acute pancreatitis (AP) and CP.ResultsPancreata from mice expressing CEL-HYB1 developed pathological features characteristic of focal pancreatitis that included acinar atrophy and vacuolization, inflammatory infiltrates, and fibrosis in a time-dependent manner. CEL-HYB1 expression in pancreatic acini led to decreased secretion and increased intracellular aggregation and triggered endoplasmic reticulum stress compared with CEL. The autophagy levels of pancreata from mice expressing CEL-HYB1 changed at different developmental stages; some aged CEL-HYB1 mice exhibited an accumulation of large autophagic vesicles and impaired autophagy in acinar cells. Administration of caerulein increased the severity of AP/CP in mice expressing CEL-HYB1 compared with control mice, accompanied by higher levels of endoplasmic reticulum stress.ConclusionsExpression of a humanized form of CEL-HYB1 in mice promotes endoplasmic reticulum stress and pancreatitis through a misfolding-dependent pathway. Impaired autophagy appears to be involved in the pancreatic injury in aged CEL-HYB1 mice. These mice have the potential to be used as a model to identify therapeutic targets for CP.

Is It a Bird? Is It a Plane? It's a Tumour – Operative Transcystic Choledochoscopy for Differentiation of Biliary Duct Filling Defect and New Early Diagnosis of Insidious Pancreatic Adenocarcinoma

Background: Operative Transcystic Choledochoscopy (OTC) during Laparoscopic Cholecystectomy (LC) is a one-procedure solution for clearance of Common Bile Duct (CBD) calculi under vision and allows identification and biopsy of biliary neoplasms. Success and complication rates in high-volume centres are similar or superior to Endoscopic Retrograde Cholangiopancreatography (ERCP). Preference for ‘minimally-invasive’ techniques like ERCP has led to infrequent use and resultant deskilling. Its ongoing role is therefore currently unclear. Case: A well 65-year-old male with epigastric pain and raised lipase, and Computed Tomography (CT) showing cholelithiasis and ‘focal pancreatitis involving the uncinate process’, underwent LC for gallstone-induced pancreatitis 6 days after presentation. Pre-operative bilirubin was normal and ALKP (133 U/L) and GGT (270 U/L) newly raised. An oedematous stone-containing gallbladder and a distal CBD filling defect on Intraoperative Cholangiogram were found. OTC demonstrated a CBD wall growth but biopsy equipment was unavailable. No peritoneal or liver metastases were seen. Ca19.9 (588 kU/L) was elevated. Pancreas-protocol CT/MRI showed a 14x14mm ‘indeterminate abnormality’ in the head/uncinate process without vascular involvement, and staging CT was negative for metastases. Endoscopic Ultrasound-guided biopsy diagnosed pancreatic adenocarcinoma following non-diagnostic ERCP. A Whipple’s procedure was planned but later abandoned as liver metastases were confirmed on frozen section at staging laparoscopy. Discussion: Despite recent movement away from OT during LC, this study highlights its utility in early identification of insidious biliary neoplasmswith the first case of preliminary pancreatic adenocarcinoma diagnosed with OTC during LC in a non-obstructed patient.

Focal IgG4-related autoimmune pancreatitis with distal choledochal adenocarcinoma: a rare case report

BackgroundAutoimmune pancreatitis (AIP) is a rare disease that manifests as pancreatic involvement in systemic IgG4-related disease (IgG4-RD), a special type of chronic pancreatitis caused by autoimmune abnormalities. The main imaging manifestations of IgG4-related AIP consist of diffuse or localized pancreatic enlargement and irregular pancreatic duct narrowing. The diagnosis of AIP is challenging because it can present with focal lesions, similar to radiologically bile duct cancer or pancreatic cancer.Case presentationA 55-year-old male patient was admitted with painless jaundice and multiple radiographic findings of pancreatic head mass, as well as intrahepatic and extrahepatic bile duct dilatation. Various imaging methods indicated pancreatic cancer. However, the endoscopic ultrasonography guided fine needle aspiration (EUS-FNA) and a laparoscopic pancreatic biopsy suggested an IgG4-related AIP. After one month, magnetic resonance imaging showed that the lesion had slightly grown. Combined with CA19-9 and other indexes, the possibility of malignancy was high and there were still surgical indications. The pathological analysis following a pancreaticoduodenectomy revealed poorly differentiated adenocarcinoma in the distal common bile duct.ConclusionTo date, few reports have described pancreatic or extrapancreatic malignancies in AIP patients, and no association between AIP and bile duct adenocarcinoma has been previously confirmed. This case discuss the differentiation between AIP and malignancy, recent research progress, and the correlation between the two diseases, highlights the importance of carefully evaluating patients with AIP to rule out potential tumors, as well as the critical need for follow up treatment.