Setting Of Chronic Pancreatitis Research Articles

Surgical Drainage of Pancreatic Pseudocyst

• A pancreatic pseudocyst is an encapsulated collection of homogenous fluid with little or no necrotic tissue within it. It is usually well circumscribed and located outside of the pancreas, often in the lesser sac. • Regardless of the cause, the overall incidence of pseudocysts is low; 0.5 to 1 per 100,000 adults per year. • Pancreatic pseudocysts are often seen as a complication of chronic pancreatitis and less commonly from acute pancreatitis • The incidence of pseudocysts is higher in males as it follows the incidence of pancreatitis, which is slightly male predominant. • In acute pancreatitis, the incidence of pseudocysts ranges from 5% to 16%. • Pseudocysts tend to be more common in the setting of chronic pancreatitis, with incidence rates between 20% to 40%. • The majority of the cases were alcohol-induced (70%) followed by biliary tract disease (8%), trauma (6%), and the remaining attributed to the idiopathic cause. • Symptoms of pseudocysts are typically non-specific and may present only with vague abdominal pain, nausea, or vomiting. • A contrast-enhanced CT scan of the abdomen is the diagnostic modality of choice. • Most pseudocysts resolve spontaneously, and treatment is usually conservative with supportive care. • In general, larger cysts are more likely to become symptomatic or cause complications. • Potential complications include infection, hemorrhage, pseudocyst rupture, and disruptions of the pancreatic duct system.

A Reduced Pancreatic Polypeptide Response is Associated With New-onset Pancreatogenic Diabetes Versus Type 2 Diabetes.

Pancreatogenic diabetes refers to diabetes mellitus (DM) that develops in the setting of a disease of the exocrine pancreas, including pancreatic ductal adenocarcinoma (PDAC) and chronic pancreatitis (CP). We sought to evaluate whether a blunted nutrient response of pancreatic polypeptide (PP) can differentiate these DM subtypes from type 2 DM (T2DM). Subjects with new-onset DM (<3 years' duration) in the setting of PDAC (PDAC-DM, n = 28), CP (CP-DM, n = 38), or T2DM (n = 99) completed a standardized mixed meal tolerance test, then serum PP concentrations were subsequently measured at a central laboratory. Two-way comparisons of PP concentrations between groups were performed using Wilcoxon rank-sum test and analysis of covariance while adjusting for age, sex, and body mass index. The fasting PP concentration was lower in both the PDAC-DM and CP-DM groups than in the T2DM group (P = 0.03 and <0.01, respectively). The fold change in PP at 15 minutes following meal stimulation was significantly lower in the PDAC-DM (median, 1.869) and CP-DM (1.813) groups compared with T2DM (3.283; P < 0.01 for both comparisons). The area under the curve of PP concentration was significantly lower in both the PDAC-DM and CP-DM groups than in T2DM regardless of the interval used for calculation and remained significant after adjustments. Fasting PP concentrations and the response to meal stimulation are reduced in new-onset DM associated with PDAC or CP compared with T2DM. These findings support further investigations into the use of PP concentrations to characterize pancreatogenic DM and to understand the pathophysiological role in exocrine pancreatic diseases (NCT03460769).

An integrated model of acinar to ductal metaplasia-related N7-methyladenosine regulators predicts prognosis and immunotherapy in pancreatic carcinoma based on digital spatial profiling

Acinar-to-ductal metaplasia (ADM) is a recently recognized, yet less well-studied, precursor lesion of pancreatic ductal adenocarcinoma (PDAC) developed in the setting of chronic pancreatitis. Through digital spatial mRNA profiling, we compared ADM and adjacent PDAC tissues from patient samples to unveil the bridging genes during the malignant transformation of pancreatitis. By comparing the bridging genes with the 7-methylguanosine (m7G)-seq dataset, we screened 19 m7G methylation genes for a subsequent large sample analysis. We constructed the “m7G score” model based on the RNA-seq data for pancreatic cancer in The Cancer Genome Atlas (TCGA) database and The Gene Expression Omnibus (GEO) database. Tumors with a high m7G score were characterized by increased immune cell infiltration, increased genomic instability, higher response rate to combined immune checkpoint inhibitors (ICIs), and overall poor survival. These findings indicate that the m7G score is associated with tumor invasiveness, immune cell infiltration, ICI treatment response, and overall patients’ survival. We also identified FN1 and ITGB1 as core genes in the m7Gscore model, which affect immune cell infiltration and genomic instability not only in pancreatic cancer but also in pan-cancer. FN1 and ITGB1 can inhibit immune T cell activition by upregulation of macrophages and neutrophils, thereby leading to immune escape of pancreatic cancer cells and reducing the response rate of ICI treatment.

S3473 Management of Splenic Subcapsular Hematoma in Setting of Chronic Pancreatitis via Percutaneous Drainage and Splenic Artery Embolization

S3473 Management of Splenic Subcapsular Hematoma in Setting of Chronic Pancreatitis via Percutaneous Drainage and Splenic Artery Embolization

Single-cell transcriptome analysis defines heterogeneity of the murine pancreatic ductal tree.

To study disease development, an inventory of an organ's cell types and understanding of physiologic function is paramount. Here, we performed single-cell RNA-sequencing to examine heterogeneity of murine pancreatic duct cells, pancreatobiliary cells, and intrapancreatic bile duct cells. We describe an epithelial-mesenchymal transitory axis in our three pancreatic duct subpopulations and identify osteopontin as a regulator of this fate decision as well as human duct cell dedifferentiation. Our results further identify functional heterogeneity within pancreatic duct subpopulations by elucidating a role for geminin in accumulation of DNA damage in the setting of chronic pancreatitis. Our findings implicate diverse functional roles for subpopulations of pancreatic duct cells in maintenance of duct cell identity and disease progression and establish a comprehensive road map of murine pancreatic duct cell, pancreatobiliary cell, and intrapancreatic bile duct cell homeostasis.

Normal pancreatic thickness values in healthy children: an MRI study

IntroductionNormal pancreatic thickness values on ultrasound (US) have been defined in literature. However, there is insufficient information about normal pancreatic measurements acquired from computed tomography (CT) or magnetic resonance imaging (MRI). To define normal pancreatic thickness measurements acquired from different localizations in order to provide reference values for more objectively identified parenchymal thickness changes. Materials and methodsA retrospective evaluation was made of the abdominal MRI examinations of 162 pediatric patients. Patients with any pancreatic disease, or chronic gastrointestinal inflammatory disease were excluded from the study. Measurements were taken from T2-weighted images. ResultsEvaluation was made of 162 children, comprising 82 (50.6%) males and 80 (49.3%) females with a mean age of 9.8 ± 2.4 years. Mean pancreatic thickness was 18.3 ± 3.1 mm, 10.2 ± 2.9 mm, 14.9 ± 3 mm, 14.9 ± 3.3 mm in head, neck, body and tail localizations, accordingly. A positive correlation was determined between age, height, weight, body mass index (BMI) and pancreatic thickness in all the anatomic localizations (r > 0.55, p < 0.05). No significant difference was determined with gender. Interobserver agreement between two researchers was moderate and strong according to the different anatomic localizations. ConclusionsThe defined normal ranges are mostly consistent with previously published US and CT based values. Pancreatic thickness values were positively correlated with age, height, weight and BMI for all four anatomical regions of the pancreas. Knowledge of normal pancreatic thickness values will increase the diagnostic accuracy of radiologists in the assessment of pancreatic diseases and may aid in interpreting atrophy in the setting of chronic pancreatitis.

Case Report: Pancreatic adenocarcinoma presenting as acute obstructive suppurative pancreatic ductitis

Acute obstructive suppurative pancreatic ductitis (AOSPD) is a rare form of infection primarily arising within the pancreatic duct in the setting of chronic pancreatitis. We present a case of AOSPD precipitated by obstructive adenocarcinoma of pancreatic head in an elderly woman with a past medical history of chronic pancreatitis, alcohol use disorder and, advanced dementia, who developed progressive abdominal pain during her hospital admission for urinary tract infection. Endoscopic retrograde cholangiopancreatography (ERCP) with balloon sweep of pus and stent placement resulted in prompt abdominal pain resolution. Our case highlights a rare presentation of AOSPD as a harbinger of pancreatic malignancy.

S1420 A Rare Case of Superior Mesenteric Vein Thrombosis as a Complication of Pancreatic Pseudocyst Fistulization

INTRODUCTION: Superior Mesenteric (SMV) Thrombus is a rare complication of acute pancreatitis, and multiple factors contribute to its formation, including underlying inflammatory along with venous compression leading to venous stasis. Here, we present a unique case of an SMV thrombus as a result of a pancreatic pseudocyst to SMV fistula in the setting of chronic pancreatitis. CASE DESCRIPTION/METHODS: Patient is a 61-year-old male with a past medical history significant for chronic pancreatitis secondary to chronic alcohol abuse who presented with multiple episodes of nausea and non-bloody, non-bilious vomiting. Labs were notable for a lipase of 161 U/L and an alcohol level >300 mg/dL. Interestingly, the patient denied any abdominal pain, and the physical exam was unremarkable, with a soft, non-tender, non-distended abdomen noted with active bowel sounds. Computed Tomography (CT) Abdomen showed chronic calcific pancreatitis with a 2.5 cm hypodense pancreatic head mass with a proximal SMV thrombosis. Magnetic Resonance Imaging (MRI) Abdomen noted the mass to be a pseudocyst rather than a primary pancreatic malignancy with visualization of a wide connection between the cyst and the adjacent SMV with resultant thrombosis of the SMV, compatible with fistulization. Furthermore, imaging did not reveal acute pancreatitis, attributing visualized fat stranding to the thrombus. Surgery recommended initiation of anti-coagulation, therefore the patient was started on a heparin drip and discharged on apixaban with close surgical follow-up. DISCUSSION: Splanchnic vein thromboses are seen in less than 2% of patients with acute pancreatitis, the majority of these involving the splenic vein, and rarely, the SMV. The pathogenesis for these thrombi is thought to be from the combination of direct damage to the venous wall by freed pancreatic enzymes and compression of the vein by the inflamed pancreas. SMV thrombosis is often diagnosed incidentally on imaging, however, it has a high mortality rate of up to 20–50% due to the risk of small bowel ischemia, therefore anti-coagulation should be considered in these cases. Uniquely in our case, the pathogenesis of the SMV thrombus included a fistula between the pancreatic pseudocyst and the SMV, which has been scarcely reported, in the setting of chronic pancreatitis rather than an acute flare. Our case also warrants the question regarding the utility of longitudinal follow-up with serial imaging in those with chronic pancreatitis to prevent fatal outcomes, including bowel ischemia.Figure 1.: CT Abdomen W Contrast 3 cm round mass is seen in the pancreatic head [red arrow], with peripheral calcifications indicating chronic pancreatitis [green arrow]. The Superior Mesenteric Vein (SMV) is in close proximity with the pancreatic mass [yellow arrow].Figure 2.: MRI Abdomen W WO Contrast (T2WI AXIAL) Revisualization of the mass in the pancreatic head with dependent debris [red arrow]. There is also fistulization from the pseudocyst into the superior mesenteric vein (SMV) [green arrow].Figure 3.: MRI Abdomen W WO Contrast (T2WI CORONAL) Mass in the pancreatic head is T2 hyperintense without wall nodularities, clearly constituting a cyst [red arrow]. There is fistulization into the Superior Mesenteric Vein (SMV) [green arrow] followed by thrombosis [blue arrow].

Finding a needle in a haystack: Endoscopic ultrasound-guided fine-needle aspiration for solid pancreatic masses in the setting of chronic pancreatitis.

Background:The mainstay for the definitive diagnosis of pancreatic lesions is endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). However, there is evidence that EUS-FNA has low sensitivity in the setting of chronic pancreatitis (CP). This single-center retrospective study aimed to compare and analyze the diagnostic yield of EUS-FNA for solid pancreatic lesions in the presence and absence of CP, and to further investigate strategies for overcoming the low diagnostic yield in the setting of CP.Methods:This study identified patients who underwent EUS-FNA at Sanford USD Medical Center (SD, USA) for a solid pancreatic lesion between July 15, 2011, and November 30, 2017. Data on demographics, clinical features, cross-sectional imaging findings, EUS findings, cytology/pathology, and clinical follow up were collected.Results:The final diagnosis was adenocarcinoma in 156 patients (67%), neuroendocrine tumor in 27 (12%), lymphoma in 6 (3%), metastatic malignancy in 8 (4%), and benign etiologies in 35 (15%). CP was identified in 44/234 (19%) patients. The overall diagnostic sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for EUS-FNA were 92.9%, 97.1%, 99.5%, 70.8%, and 93.5%, respectively. The sensitivity (80% vs. 95%, P=0.020) and accuracy (86% vs. 95%, P=0.043) were significantly lower in patients with CP compared to those without CP.Conclusion:CP can significantly affect the EUS-FNA diagnostic yield of solid pancreatic neoplasms. A high index of clinical suspicion is required in these cases to make a definitive diagnosis.

Endoscopic Therapy for Recurrent Acute Pancreatitis

Recurrent acute pancreatitis (RAP) is a clinical entity characterized by episodes of acute pancreatitis which occurs on more than one occasion. Recurrence of pancreatitis generally occurs in a setting of a normal anatomical and functional gland, however, a chronic disease at early stage may be found either on the occasion of the first episode of pancreatitis or during the follow-up. The etiology of RAP can be identified in up to 70% of cases; for the remaining cases the term “idiopathic” is used. Most common causes include bile duct stone disease, sphincter of Oddi dysfunction, anatomical ductal variants interfering with pancreatic juice outflow, genetic mutations, any obstruction of the main pancreatic duct or pancreatico-biliary junction, and alcohol consumption. Patients with RAP have few treatment options available to them to manage their symptoms or prevent progression to chronic pancreatitis. Endoscopic therapy has been found effective in those cases in whom a mechanical obstruction is found. The efficacy of endoscopic therapy in patients with a history of RAP depends on two main factors: whether or not the bouts of acute pancreatitis occur in a normal pancreas or in a setting of chronic pancreatitis, and whether or not a cause can be identified and removed. Because occult bile stone disease and sphincter of Oddi dysfunction account for the majority of cases, cholecystectomy, and eventually endoscopic biliary and/or pancreatic sphincterotomy are curative in most of cases. However, in the last years concerns the efficacy of endotherapy in sphincter of Oddi dysfunction have been raised. Pancreatic endotherapy has been proven effective in cases of recurrent pancreatitis caused by pancreatic ductal obstruction, independently from the cause of obstruction, in symptomatic pancreas divisum and in some cases of genetic mutations.

1262 A Rare Case of Pleural Effusion Due to a Pancreatico-Pleural Fistula in the Setting of Pancreas Divisum

INTRODUCTION: A pancreatico pleural fistula is a rare complication of pancreatitis which classically results from a pancreatic duct disruption or a pseudocyst extension into the pleural cavity. The literature present on this condition continues to remain sparse. We attempt to present a rare case of a pancreatico-pleural fistula in the setting of a congenital pancreatic anomaly which initially presented as a recurrent pleural effusion in the setting of chronic pancreatitis. CASE DESCRIPTION/METHODS: Our patient was a 51-year-old female who presented with intractable abdominal pain and shortness of breath with a confirmed diagnosis of a pancreatic pseudocyst. On admission, her chest Xray was significant for pleural effusion. Further analysis of the pleural fluid revealed the presence of elevated lipase and amylase levels. The patient eventually underwent an ERCP with contrast that revealed contrast leakage tracking upwards from the dorsal pancreatic duct suggesting a pancreatico-pleural fistula. This was in addition to the inability to fill the ventral pancreatic duct, suggesting a complete pancreatic divisum. A pancreatic duct plastic stent was placed and the pleural effusion gradually subsequently subsided. DISCUSSION: The case allows us to consider one of the lesser known etiologies of pleural effusion in the setting of pancreatitis (the other one being transdiaphragmatic lymphatic blockage) and provides us with an opportunity to develop a step to manage the same. This is the only known case report of a pancreatico-pleural fistula with a concomitant complete pancreatic divisum.

Long-term follow-up after multiple plastic stenting for refractory pancreatic duct strictures in chronic pancreatitis.

Dominant pancreatic duct strictures in chronic pancreatitis are often managed by endoscopic placement of a single plastic stent. Insertion of multiple plastic stents (MPS) has been proven to be effective in managing refractory strictures, but data are still limited. The aim of this study was to investigate the efficacy and long-term results of MPS to dilate pancreatic duct strictures in chronic pancreatitis. 48 patients (34 men; mean age 44 years) with chronic pancreatitis and a single pancreatic stent through a refractory stricture in the pancreatic head underwent the following protocol: 1)removal of the single pancreatic stent; 2)balloon dilation of the stricture; 3)insertion of the maximum number of stents; 4)stent removal after 6 - 12 months. The median number of pancreatic plastic stents placed was 3 (diameter 7 - 11.5 Fr, length 3 - 7 cm). Five patients (10.4 %) had persistent strictures after MPS removal. During a mean follow-up of 9.5 years (0.3 - 15.5 years) after stent removal, 74.4 % (32/43) of the patients were asymptomatic, and 25.6 % (11/43) experienced pancreatitis recurrence or pancreatic type pain after a mean time of 26.4 months (8/43, 18.6 % underwent plug extraction without evidence of stricture recurrence; 3/43, 7.0 % had stricture recurrence). No major complications were recorded. Endoscopic multiple plastic stenting of chronic pancreatitis-related pancreatic duct strictures showed satisfactory long-term results, with the option of re-treatment. This procedure can be considered an important therapeutic alternative for painful pancreatic duct strictures located in the head of the pancreas in the setting of chronic pancreatitis.

Pancreaticopleural fistula: a case report

Pancreaticopleural fistula is a diagnostic challenge to physicians. The diagnosis should be suspected if a patient presents with pleural effusion in a setting of chronic pancreatitis. The significantly raised amylase in the pleural fluid offers an important clue to the diagnosis. Computed Tomography (CT), Endoscopic retrograde cholangiopancreatography (ERCP) and Magnetic resonance cholangiopancreatography (MRCP) can reveal the fistulous tract between the pancreas and the pleural space. The therapeutic options include medical, endoscopic, as well as surgical interventions. Here we report a case of pancreaticopleural fistula in a chronic alcoholic that was treated successfully by medical management.

Increased Chromogranin A-Positive Hormone-Negative Cells in Chronic Pancreatitis.

Chronic pancreatitis (CP) is characterized by inflammation, fibrosis, and a loss of pancreatic acinar cells, which can result in exocrine and eventually endocrine deficiency. Pancreatitis has been reported to induce formation of new endocrine cells (neogenesis) in mice. Our recent data have implicated chromogranin A-positive hormone-negative (CPHN) cells as potential evidence of neogenesis in humans. We sought to establish if CPHN cells were more abundant in CP in humans. We investigated the frequency and distribution of CPHN cells and the expression of the chemokine C-X-C motif ligand 10 (CXCL10) and its receptor chemokine C-X-C motif receptor 3 in pancreas of nondiabetic subjects with CP. CPHN cell frequency in islets was increased sevenfold in CP [2.1% ± 0.67% vs 0.35% ± 0.09% CPHN cells in islets, CP vs nonpancreatitis (NP), P < 0.01], as were the CPHN cells found as scattered cells in the exocrine areas (17.4 ± 2.9 vs 4.2 ± 0.6, CP vs NP, P < 0.001). Polyhormonal endocrine cells were also increased in CP (2.7 ± 1.2 vs 0.1 ± 0.04, CP vs NP, % of polyhormonal cells of total endocrine cells, P < 0.01), as was expression of CXCL10 in α and β cells. There is increased islet endogenous expression of the inflammation marker CXCL10 in islets in the setting of nondiabetic CP and an increase in polyhormonal (insulin-glucagon expressing) cells. The increase in CPHN cells in CP, often in a lobular distribution, may indicate foci of attempted endocrine cell regeneration.

Pancreatic head excavation for tissue diagnosis may reduce unnecessary pancreaticoduodenectomies in the setting of chronic pancreatitis

The necessity to obtain a tissue diagnosis of cancer prior to pancreatic surgery still remains an open debate. In fact, a non-negligible percentage of patients undergoing pancreaticoduodenectomy (PD) for suspected cancer has a benign lesion at final histology. We describe an approach for patients with diagnostic uncertainty between cancer and chronic pancreatitis, with the aim of minimizing the incidence of PD for suspicious malignancy finally diagnosed as benign disease. Eighty-eight patients (85.4%) with a clinicoradiological picture highly suggestive for malignancy received formal PD (group 1). Fifteen patients (14.6%) in whom preoperative diagnosis was uncertain between pancreatic cancer and chronic pancreatitis underwent pancreatic head excavation (PHEX) for intraoperative tissue diagnosis (group 2): those diagnosed as having cancer received PD, whereas those with chronic pancreatitis received pancreaticojejunostomy (PJ). No patient received PD for benign disease. All patients in group 1 had adenocarcinoma on final histology. Eight patients of group 2 (53.3%) received PD after intraoperative diagnosis of cancer, whereas 7 (46.7%) received PJ because no malignancy was found at introperative frozen sections. No signs of cancer were encountered in patients receiving PHEX and PJ after a median follow-up of 42 months. Overall survival did not differ between patients receiving PD for cancer in the group 1 and those receiving PD for cancer after PHEX in the group 2 (P=0.509). Although the described technique has been used in a very selected group of patients, our results suggest that PHEX for tissue diagnosis may reduce rates of unnecessary PD, when the preoperative diagnosis is uncertain between cancer and chronic pancreatitis.

Livedo Reticularis in Setting of Chronic Pancreatitis

Livedo Reticularis in Setting of Chronic Pancreatitis

A Case of a Chronic Pancreatic Pseudocyst Causing Atraumatic Splenic Rupture without Evidence of Acute Pancreatitis.

Atraumatic splenic rupture is a rare complication of a pancreatic pseudocyst (PP), described in the setting of chronic pancreatitis. There is common understanding, within the literature, that an inflammatory process at the tail of the pancreas may disrupt the spleen and result in such splenic complications. The authors present a case report of a 29-year-old male with a PP, associated with chronic pancreatitis. The patient had a history of excessive alcohol intake and presented to the emergency department with a short history of abdominal pain and vomiting. He denied any significant history of trauma and serum amylase levels were normal. An admission computed tomography (CT) scan of the abdomen confirmed the presence of a PP in direct contact with the spleen. The CT also demonstrated a heterogenous hypodense area of the splenic hilum, along with perisplenic fluid. The patient was admitted for observation. His abdominal pain progressed, and he became haemodynamically unstable. An emergency ultrasound scan (USS) at this time revealed intra-abdominal haemorrhage. A subsequent CT confirmed splenic rupture, which was managed surgically with a full recovery. Few such cases are documented within the literature and more understanding of preempting such events is needed.

Improving the results of pancreatic endoscopic ultrasound-guided fine needle aspiration in daily practice: keep it simple.

Improving the results of pancreatic endoscopic ultrasound-guided fine needle aspiration in daily practice: keep it simple.

Surviving Primary Pancreatic Squamous Cell Carcinoma: A Rare Entity: Presidential Poster

Introduction: The pancreas is devoid of any squamous cells and the origin of a pancreatic carcinoma with primary squamous morphology is rarely described with little known about the natural history following treatment. Case Report: A 76-year-old Caucasian male, presented with a history of weight loss, painless jaundice and abdominal pain. His liver enzyme elevation was consistent with a cholestatic pattern. A CT abdomen revealed a 4.1 x 4.9 x 5.0 cm enhancing inhomogeneous malignant-appearing mass in the head of the pancreas with dilation of the common bile duct. Endoscopic retrograde cholangiopancreatography identified a biliary stricture and an ampullary stent was placed. Brushings from the stricture did not reveal any malignant cells. Cytological examination of an endosonographically-guided fine needle aspiration specimen confirmed the diagnosis revealing a moderately differentiated squamous cell carcinoma with no glandular differentiation and positive immunostaining for CK 5/6 and p63. No other primary site for squamous cell carcinoma was identified. Since the tumor was in close proximity to the superior mesenteric artery, the surgical risk was high. The patient was treated with concurrent chemotherapy (5-fluorouracil) and radiotherapy. The patient was closely followed with biliary stent changes and surveillance imaging. He has shown a progression free survival of 13 months, the longest so far reported in the literature. Pure pancreatic squamous cell cancer is very uncommon with an incidence of 0.5% to 2% of all exocrine pancreatic neoplasms. It is often presumed to be metastatic from another primary site unless proven otherwise. It is postulated to originate either in squamous metaplasia in a setting of chronic pancreatitis, in a pre-existing adenocarcinoma or differentiation of primitive multipotent cells with malignant transformation. CT imaging is helpful in staging or determining primary malignancies elsewhere if any. Enhancement of tumor on contrast CT and tumor blush on angiography helps to differentiate squamous cell from adenocarcinoma due to its rich vascularity. It is an aggressive tumor with a dire prognosis. Surgical resection is the best curative option but often limited by local and/or distant metastasis. Chemotherapeutic options include 5-fluorouracil, Gemcitabine and platinum based regimens, with variable success rates and a reported median survival of 3 months. We present a rare case of an aggressive primary pancreatic squamous cell cancer with the longest reported cancer free survival following chemotherapy.

Superior Mesenteric Vein Pseudoaneurysm Presenting as a Pancreatic Mass

Introduction: A 67-year-old man with a past history of hypertension and long-standing alcohol abuse was admitted for shortness of breath secondary to new-onset heart failure. His hospital course was complicated by hypertensive emergency and delirium tremens requiring intubation and midazolam drip. An ultrasound of the abdomen was performed to evaluate for cirrhosis and revealed a questionable mass in the uncinate process of the pancreas and a dilated pancreatic duct to 6 mm in the head. At this time GI was consulted for further evaluation. A palpable epigastric mass was noted on physical exam and labs revealed a low albumin, 2.5 g/dL. Liver function tests, amylase, lipase, and coagulation studies were otherwise normal. CT scan of the abdomen demonstrated a 2.8 x 3.2 x 2.8 cm enhancing lesion concerning for a tumor in the area of the pancreatic head and superior mesenteric vein (SMV). Endoscopic ultrasound (EUS) was performed and revealed a dilated SMV to 25 x 21 mm with pseudoaneurysm formation. The EUS also revealed multiple criteria to establish a diagnosis of chronic pancreatitis. Arteriogram was performed and did not show an arteriovenous malformation. The patient was diagnosed with a SMV pseudoaneurysm and discharged in stable condition, remaining asymptomatic upon outpatient follow-up. Pseudoaneurysms are a rare complication of chronic pancreatitis. It is theorized that pancreatic enzymes may erode the peripancreatic vessels and result in the formation of a pseudoaneurysm. Vessels commonly affected include the splenic, hepatic, gastroduodenal, and cystic arteries. Eighty-nine percent of patients with a pseudoaneurysm complain of abdominal pain and complications include thrombosis and bleeding. When bleeding occurs, surgery is complicated and is associated with a high morbidity and mortality. Conservative management with serial abdominal imaging, usually ultrasound, is generally recommended, as 94% of pseudoaneurysms remain stable and a much smaller percentage regress. We found no published cases of SMV pseudoaneurysms mimicking pancreatic cancer. We present a unique case of an asymptomatic patient with SMV pseudoaneurysm from chronic alcoholic pancreatitis masquerading as pancreatic cancer. Vascular pseudoaneurysms must be considered in the setting of chronic pancreatitis, especially when a mass-like lesion is discovered.Figure 1