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de Ponthaud C, Daire E, Pioche M, Napoléon B, Fillon M, Sauvanet A, Gaujoux S. Cystic dystrophy in heterotopic pancreas. J Visc Surg 2023; 160:108-117. [PMID: 36966112 DOI: 10.1016/j.jviscsurg.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2023]
Abstract
Cystic dystrophy in heterotopic pancreas, or paraduodenal pancreatitis, is a rare and complicated presentation involving heterotopic pancreatic tissue in the duodenal wall. This condition is present in 5% of the general population but disease mainly affects middle-aged alcoholic-smoking men with chronic pancreatitis (CP). It may be purely duodenal or segmental (pancreatico-duodenopathy). Its pathophysiology arises from alcohol toxicity with obstruction of small ducts of heterotopic pancreatic tissue present in the duodenal wall and the pancreatic-duodenal sulcus, leading to repeated episodes of pancreatitis. The symptomatology includes episodes of acute pancreatitis, weight loss, and vomiting due to duodenal obstruction. Imaging shows thickening of the wall of the second portion of the duodenum with multiple small cysts. A stepwise therapeutic approach is preferred. Conservative medical treatment is favored in first intention (analgesics, continuous enteral feeding, somatostatin analogues), which allows complete symptomatic regression in 57% of cases associated with a 5% rate of complications (arterial thrombosis and diabetes). Endoscopic treatment may also be associated with conservative measures. Surgery achieves a complete regression of symptoms in 79% of cases but with a 20% rate of complications. Surgery is indicated in case of therapeutic failure or in case of doubt about a malignant tumor. Pancreaticoduodenectomy and duodenal resection with pancreatic preservation (PPDR) seem to be the most effective treatments. PPDR has also been proposed as a first-line treatment for purely duodenal location of paraduodenal pancreatitis, thereby preventing progression to an extended segmental form.
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Affiliation(s)
- C de Ponthaud
- Department of hepatobiliary and pancreatic surgery and liver transplantation, Pitié-Salpêtrière hospital, AP-HP, Paris, France; Department of general, visceral and endocrine surgery, Pitié-Salpêtrière hospital, AP-HP, Paris, France; Sorbonne university, Paris, France
| | - E Daire
- Gastroenterology department, Édouard-Herriot hospital, Lyon, France
| | - M Pioche
- Gastroenterology department, Édouard-Herriot hospital, Lyon, France
| | - B Napoléon
- Gastroenterology department, Jean Mermoz hospital, Lyon, France
| | - M Fillon
- Radiology department, la Croix Rousse hospital, Lyon, France
| | - A Sauvanet
- Pancreatic and hepatobiliary surgery department, Beaujon hospital, AP-HP, Clichy, France; University of Paris, France
| | - S Gaujoux
- Department of hepatobiliary and pancreatic surgery and liver transplantation, Pitié-Salpêtrière hospital, AP-HP, Paris, France; Department of general, visceral and endocrine surgery, Pitié-Salpêtrière hospital, AP-HP, Paris, France; Sorbonne university, Paris, France.
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2
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Yamashita Y, Ashida R, Kitano M. Imaging of Fibrosis in Chronic Pancreatitis. Front Physiol 2022; 12:800516. [PMID: 35082692 PMCID: PMC8784507 DOI: 10.3389/fphys.2021.800516] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 12/03/2021] [Indexed: 12/12/2022] Open
Abstract
Chronic pancreatitis (CP) describes long-standing inflammation of the pancreas, which leads to irreversible and progressive inflammation of the pancreas with fibrosis. CP also leads to abdominal pain, malnutrition, and permanent impairment of exocrine/endocrine functions. However, it is difficult to assess CP pathologically, and imaging modalities therefore play an important role in the diagnosis and assessment of CP. There are four modalities typically used to assess CP. Pancreatic duct features are assessed with magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP). However, ERCP is a rather invasive diagnostic modality for CP, and can result in adverse events such as post-ERCP pancreatitis. Computed tomography (CT) is often the most appropriate initial imaging modality for patients with suspected CP, and has high diagnostic specificity. However, CT findings typically only appear in advanced stages of CP, and it is difficult to detect early CP. Endoscopic ultrasonography (EUS) provides superior spatial resolution compared with other imaging modalities such as CT and magnetic resonance imaging (MRI), and is considered the most reliable and efficient diagnostic modality for pancreatic diseases. The EUS-based Rosemont classification plays an important role in diagnosing CP in clinical practice. Evaluation of tissue stiffness can be another option to assess the diagnosis and progression of CP, and MRI and EUS can be used to assess CP not only with imaging, but also with elasticity measurement. MR and EUS elastography are expected to provide new alternative diagnostic tools for assessment of fibrosis in CP, which is difficult to evaluate pathologically.
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Affiliation(s)
- Yasunobu Yamashita
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Reiko Ashida
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Masayuki Kitano
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
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Terra C, Ramos-Andrade D, Sá-Marques I, Brito J, Caseiro-Alves F, Curvo-Semedo L. Duodenal imaging on the spotlight: from A to Z. Insights Imaging 2021; 12:94. [PMID: 34232417 PMCID: PMC8263847 DOI: 10.1186/s13244-021-01045-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 06/18/2021] [Indexed: 12/14/2022] Open
Abstract
Abdominal computed tomography (CT) is frequently performed to evaluate gastrointestinal pathologic conditions. The majority of the gastrointestinal radiology literature has concentrated on the colon, stomach, and distal small bowel. The duodenum is often overlooked on imaging, namely on CT, but its anatomy (intra and retroperitoneal) and location in such close proximity to other viscera results in involvement by a multitude of primary and secondary processes, some of them exclusive to this bowel segment. While some conditions, like duplications, lipomas, and diverticula, are usually asymptomatic and are incidentalomas that have no pathologic significance, others are symptomatic and very relevant and should be recognized by every general radiologist: development conditions such as annular pancreas and gut malrotation; inflammatory processes such as ulcers and secondary involvement from pancreatitis; neoplastic conditions such as adenocarcinoma, lymphoma, or local extension from adjacent malignancies. They all can be reliably diagnosed with CT. In this article, we demonstrate the typical imaging features of various diseases involving the duodenum, such as developmental, traumatic, inflammatory, infectious, neoplastic, and postsurgical pathologic conditions in alphabetical order, focusing mainly on upper gastrointestinal series (UGIS) and CT but also some radiography, ultrasound, and magnetic resonance (MR) imaging.
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Affiliation(s)
- Carolina Terra
- Department of Radiology, Centro Hospitalar e Universitário de Coimbra, Praceta Prof. Mota Pinto, 3004-561, Coimbra, Portugal.
| | - Daniel Ramos-Andrade
- Department of Radiology, Centro Hospitalar e Universitário de Coimbra, Praceta Prof. Mota Pinto, 3004-561, Coimbra, Portugal
| | - Ivo Sá-Marques
- Department of Radiology, Centro Hospitalar e Universitário de Coimbra, Praceta Prof. Mota Pinto, 3004-561, Coimbra, Portugal
| | - Jorge Brito
- Centro Hospitalar do Algarve, Faro, Portugal
| | - Filipe Caseiro-Alves
- Department of Radiology, Centro Hospitalar e Universitário de Coimbra, Praceta Prof. Mota Pinto, 3004-561, Coimbra, Portugal
| | - Luís Curvo-Semedo
- Department of Radiology, Centro Hospitalar e Universitário de Coimbra, Praceta Prof. Mota Pinto, 3004-561, Coimbra, Portugal
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Wolske KM, Ponnatapura J, Kolokythas O, Burke LMB, Tappouni R, Lalwani N. Chronic Pancreatitis or Pancreatic Tumor? A Problem-solving Approach. Radiographics 2019; 39:1965-1982. [PMID: 31584860 DOI: 10.1148/rg.2019190011] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Certain inflammatory pancreatic abnormalities may mimic pancreatic ductal adenocarcinoma at imaging, which precludes accurate preoperative diagnosis and may lead to unnecessary surgery. Inflammatory conditions that may appear masslike include mass-forming chronic pancreatitis, focal autoimmune pancreatitis, and paraduodenal pancreatitis or "groove pancreatitis." In addition, obstructive chronic pancreatitis can mimic an obstructing ampullary mass or main duct intraductal papillary mucinous neoplasm. Secondary imaging features such as the duct-penetrating sign, biliary or main pancreatic duct skip strictures, a capsulelike rim, the pancreatic duct-to-parenchyma ratio, displaced calcifications in patients with chronic calcific pancreatitis, the "double duct" sign, and vessel encasement or displacement can help to suggest the possibility of an inflammatory mass or a neoplastic process. An awareness of the secondary signs that favor a diagnosis of malignant or inflammatory lesions in the pancreas can help the radiologist to perform the differential diagnosis and determine the degree of suspicion for malignancy. Repeat biopsy or surgical resection may be necessary to achieve an accurate diagnosis and prevent unnecessary surgery for inflammatory conditions. Online supplemental material and DICOM image stacks are available for this article. ©RSNA, 2019.
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Affiliation(s)
- Kristy Marie Wolske
- From the Departments of Radiology of Wake Forest Baptist Medical Center, 1 Medical Center Blvd, Winston-Salem, NC 27157 (K.M.W., J.P., R.T., N.L.); University of Washington, Seattle, Wash (O.K.); and University of North Carolina at Chapel Hill, Chapel Hill, NC (L.M.B.B.)
| | - Janardhana Ponnatapura
- From the Departments of Radiology of Wake Forest Baptist Medical Center, 1 Medical Center Blvd, Winston-Salem, NC 27157 (K.M.W., J.P., R.T., N.L.); University of Washington, Seattle, Wash (O.K.); and University of North Carolina at Chapel Hill, Chapel Hill, NC (L.M.B.B.)
| | - Orpheus Kolokythas
- From the Departments of Radiology of Wake Forest Baptist Medical Center, 1 Medical Center Blvd, Winston-Salem, NC 27157 (K.M.W., J.P., R.T., N.L.); University of Washington, Seattle, Wash (O.K.); and University of North Carolina at Chapel Hill, Chapel Hill, NC (L.M.B.B.)
| | - Lauren M B Burke
- From the Departments of Radiology of Wake Forest Baptist Medical Center, 1 Medical Center Blvd, Winston-Salem, NC 27157 (K.M.W., J.P., R.T., N.L.); University of Washington, Seattle, Wash (O.K.); and University of North Carolina at Chapel Hill, Chapel Hill, NC (L.M.B.B.)
| | - Rafel Tappouni
- From the Departments of Radiology of Wake Forest Baptist Medical Center, 1 Medical Center Blvd, Winston-Salem, NC 27157 (K.M.W., J.P., R.T., N.L.); University of Washington, Seattle, Wash (O.K.); and University of North Carolina at Chapel Hill, Chapel Hill, NC (L.M.B.B.)
| | - Neeraj Lalwani
- From the Departments of Radiology of Wake Forest Baptist Medical Center, 1 Medical Center Blvd, Winston-Salem, NC 27157 (K.M.W., J.P., R.T., N.L.); University of Washington, Seattle, Wash (O.K.); and University of North Carolina at Chapel Hill, Chapel Hill, NC (L.M.B.B.)
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Abstract
OBJECTIVES This study aimed to evaluate the clinical and radiological features and clinical outcomes of paraduodenal pancreatitis (PP). METHODS A final diagnosis of PP was based on surgical specimens in resected patients and on imaging in nonoperated patients. Clinical, radiological, and pathological data were collected and reevaluated. RESULTS We studied 120 patients, 97.5% of whom were drinkers and 97.5% were smokers. Symptoms at clinical onset were acute pancreatitis in 78 patients (65%) and continuous pain in 68 patients (55.8%). Other symptoms were vomiting (36.7%), weight loss (25.8%), and jaundice (11.7%). Cystic variant was diagnosed in 82 patients (68.0%), and solid variant was diagnosed in 38 patients (32.0%). Pure and diffuse forms were observed in 22 (18.3%) and 98 (81.7%) patients, respectively. Pancreatic calcifications were present at clinical onset in 5.0% of the patients and in 61.0% at the end of follow-up. Somatostatin analogs were used in 13 patients (10.8%), and 81 patients (67.0%) underwent surgery. CONCLUSIONS The clinical profile of PP was found to be middle-aged men who were heavy drinkers and smokers with painful pancreatitis and was associated with vomiting and weight loss. In nonresponders, alcohol withdrawal and medical therapy can be proposed as a first-line treatment, and surgery as a second-line treatment.
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Campos LP, Mateu CA, García-Argüelles JS, Durá Ayet AB, Pérez IB, Callol PS. Cystic dystrophy of the duodenal wall: A rare but need-to-know disease. Endosc Ultrasound 2017; 6:61-66. [PMID: 28218203 PMCID: PMC5331846 DOI: 10.4103/2303-9027.200207] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Cystic dystrophy of the duodenal wall (CDDW) is a serious but uncommon complication of heterotopic pancreatic tissue characterized by increased duodenal wall thickness associated with intraparietal cystic lesions. It is mainly observed in middle-aged male patients with alcoholic chronic pancreatitis. Clinical symptoms are usually nonspecific and it is important to take them into account in patients with the abovementioned history. Imaging techniques have been useful for diagnosis, especially endoscopic ultrasound (EUS), to visualize cystic lesions in the wall. There is some controversy regarding treatment, because although good results have been obtained with surgical techniques, the recent emergence of EUS-guided drainages has also achieved acceptable results and they are suggested as a good alternative to traditional surgery. Following is our experience in the diagnosis and treatment of four patients with CDDWs; all of whom had a history of alcoholism and smoking, and were studied due to clinical signs of abdominal pain and vomiting. EUS was particularly useful in reaching the final diagnosis.
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Affiliation(s)
- Lydia Plana Campos
- Department of Digestive Diseases, University General Hospital Consortium, Valencia, Spain
| | - Carlos Alventosa Mateu
- Department of Digestive Diseases, University General Hospital Consortium, Valencia, Spain
| | | | - Ana Belén Durá Ayet
- Department of Digestive Diseases, University General Hospital Consortium, Valencia, Spain
| | - Inma Bort Pérez
- Department of Digestive Diseases, University General Hospital Consortium, Valencia, Spain
| | - Patricia Suárez Callol
- Department of Digestive Diseases, University General Hospital Consortium, Valencia, Spain
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Di Serafino M, Severino R, Brigida R, Scarano E. Cystic dystrophy of the duodenal wall in heterotopic pancreas: an atypical case in non-alcoholic female. BJR Case Rep 2016; 2:20160058. [PMID: 30460038 PMCID: PMC6243317 DOI: 10.1259/bjrcr.20160058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Revised: 04/16/2016] [Accepted: 05/11/2016] [Indexed: 12/14/2022] Open
Abstract
Cystic dystrophy of the duodenal wall in heterotopic pancreas, recently described as paraduodenal pancreatitis, is a rare condition characterized by multiple cysts or pseudocysts located in the submucosa or muscularis propria of a thickened duodenal wall. They result from multiple episodes of obstruction of the small ducts in aberrant pancreatic islets. Cystic dystrophy of the duodenal wall in heterotopic pancreas usually affects alcoholic males, but here we present the case of a female without a history of alcohol abuse who was referred to our emergency department with abdominal pain and vomiting. She was treated by a pancreas-preserving surgical approach, thanks to a proper pre-operative differential diagnosis. Even though differentiating this benign condition from pancreatic cancer is a challenge, some characteristic findings on multidetector CT scan and MRI/MR cholangiopancreatography, such as a thickened duodenal wall containing cysts and sheet-like tissues in the pancreaticoduodenal groove, could lead to the correct diagnosis.
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Affiliation(s)
| | - Rosa Severino
- Radiology Department, Federico II University Hospital, Napoli, Italy
| | - Raffaela Brigida
- Emergency Radiology Department, San Carlo Hospital, Potenza, Italy
| | - Enrico Scarano
- Emergency Radiology Department, San Carlo Hospital, Potenza, Italy
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8
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Multidetector CT imaging of the pancreatic groove: differentiating carcinomas from paraduodenal pancreatitis. Clin Imaging 2016; 40:1246-1252. [DOI: 10.1016/j.clinimag.2016.08.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 06/23/2016] [Accepted: 08/02/2016] [Indexed: 01/16/2023]
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9
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Vinokurova LV, Khatkov IE, Izrailov RE, Bordin DS, Dubtsova EA, Nikolskaya KA, Agafonov MA, Andrianov AV. [Duodenal dystrophy: An interdisciplinary problem]. TERAPEVT ARKH 2016; 88:71-74. [PMID: 27030187 DOI: 10.17116/terarkh201688271-74] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
Duodenal dystrophy (DD) is the pathological change in the wall of the duodenum, which is caused by chronic inflammation in its ectopic pancreatic tissue. The most common complications of DD are acute or chronic pancreatitis and impaired duodenal patency, which along with severe pain are an indication for surgical treatment. Pancreaticoduodenal resection is recognized as the operation of choice. The paper describes a clinical case demonstrating the efficiency and safety of minimally invasive (laparoscopic) surgical technologies in this category of patients. Resectional interventions of this volume are also shown to be accompanied by the development of pancreatic insufficiency that necessitates continuous enzyme replacement therapy.
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Affiliation(s)
- L V Vinokurova
- Moscow Clinical Research and Practical Center, Moscow Healthcare Department, Moscow, Russia
| | - I E Khatkov
- Moscow Clinical Research and Practical Center, Moscow Healthcare Department, Moscow, Russia
| | - R E Izrailov
- Moscow Clinical Research and Practical Center, Moscow Healthcare Department, Moscow, Russia
| | - D S Bordin
- Moscow Clinical Research and Practical Center, Moscow Healthcare Department, Moscow, Russia
| | - E A Dubtsova
- Moscow Clinical Research and Practical Center, Moscow Healthcare Department, Moscow, Russia
| | - K A Nikolskaya
- Moscow Clinical Research and Practical Center, Moscow Healthcare Department, Moscow, Russia
| | - M A Agafonov
- Moscow Clinical Research and Practical Center, Moscow Healthcare Department, Moscow, Russia
| | - A V Andrianov
- Moscow Clinical Research and Practical Center, Moscow Healthcare Department, Moscow, Russia
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Cystic form of paraduodenal pancreatitis (cystic dystrophy in heterotopic pancreas (CDHP)): a potential link with minor papilla abnormalities? A study in a large series. Eur Radiol 2015; 26:199-205. [PMID: 25991480 DOI: 10.1007/s00330-015-3799-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 04/07/2015] [Accepted: 04/13/2015] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To analyze the association between cystic dystrophy in the heterotopic pancreas (CDHP) and minor papilla abnormalities. MATERIAL AND METHODS 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. RESULTS 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). CONCLUSION 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. KEY POINTS 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.
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11
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Frequency and characterization of benign lesions in patients undergoing surgery for the suspicion of solid pancreatic neoplasm. Pancreas 2014; 43:1329-33. [PMID: 25058888 DOI: 10.1097/mpa.0000000000000193] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVES A diagnosis of benign lesions (BLs) is reported in 5% to 21% of pancreatoduodenectomies performed for neoplasms; no data for body-tail resections are available. The aims were to investigate the frequency and characterize the BLs mimicking cancer in the head and the body-tail of the pancreas. METHODS This study is a retrospective review of pancreatic specimenscollected from 2005 to 2011 in the pathology database of Mainz (Germany). Patients with final diagnosis excluding malignancy were analyzed by histology, imaging, and clinical aspects. RESULTS Among 373 patients, 33 patients (8.8%) were diagnosed with a benign disease: 25 (8.4%) of 298 in the pancreatic head and 8 (10.7%) of 75 in the body-tail resections. Paraduodenal pancreatitis was diagnosed in 13 (3.5%) of 373 patients; autoimmune pancreatitis (AIP), in 11 (2.9%); "ordinary" chronic pancreatitis, in 6 (1.6%); and accessory spleen, in 3 (0.8%). In pancreatic head resections, the most frequent diagnoses were paraduodenal pancreatitis (13/298, 4.4%) and AIP (9/298, 3%), whereas in the body-tail, the most frequent diagnoses were accessory spleen (3/75, 4%), chronic pancreatitis (3/75, 4%), and AIP (2/75, 2.7%). CONCLUSIONS Benign lesions are observed with the same frequency inspecimens of the head or the body-tail of the pancreas.
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12
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Gupta P, Debi U, Sinha SK, Prasad KK. Upper gastrointestinal barium evaluation of duodenal pathology: A pictorial review. World J Radiol 2014; 6:613-618. [PMID: 25170399 PMCID: PMC4147442 DOI: 10.4329/wjr.v6.i8.613] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Revised: 04/15/2014] [Accepted: 07/18/2014] [Indexed: 02/06/2023] Open
Abstract
Like other parts of the gastrointestinal tract (GIT), duodenum is subject to a variety of lesions both congenital and acquired. However, unlike other parts of the GIT viz. esophagus, rest of the small intestine and large intestine, barium evaluation of duodenal lesions is technically more challenging and hence not frequently reported. With significant advances in computed tomography technology, a thorough evaluation including intraluminal, mural and extramural is feasible in a single non-invasive examination. Notwithstanding, barium evaluation still remains the initial and sometimes the only imaging study in several parts of the world. Hence, a thorough acquaintance with the morphology of various duodenal lesions on upper gastrointestinal barium examination is essential in guiding further evaluation. We reviewed our experience with various common and uncommon barium findings in duodenal abnormalities.
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13
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Egorov VI, Vankovich AN, Petrov RV, Starostina NS, Butkevich AT, Sazhin AV, Stepanova EA. Pancreas-preserving approach to "paraduodenal pancreatitis" treatment: why, when, and how? Experience of treatment of 62 patients with duodenal dystrophy. BIOMED RESEARCH INTERNATIONAL 2014; 2014:185265. [PMID: 24995273 PMCID: PMC4066689 DOI: 10.1155/2014/185265] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 05/11/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND The term "paraduodenal pancreatitis" (PP) was proposed as a synonym for duodenal dystrophy (DD) and groove pancreatitis, but it is still unclear what organ PP originates from and how to treat it properly. OBJECTIVE To assess the results of different types of treatment for PP. METHOD Prospective analysis of 62 cases of PP (2004-2013) with histopathology of 40 specimens was performed; clinical presentation was assessed and the results of treatment were recorded. RESULTS Preoperative diagnosis was correct in all the cases except one (1.9%). Patients presented with abdominal pain (100%), weight loss (76%), vomiting (30%), and jaundice (18%). CT, MRI, and endoUS were the most useful diagnostic modalities. Ten patients were treated conservatively, 24 underwent pancreaticoduodenectomies (PD), pancreatico- and cystoenterostomies (8), Nakao procedures (5), duodenum-preserving pancreatic head resections (5), and 10 pancreas-preserving duodenal resections (PPDR) without mortality. Full pain control was achieved after PPRDs in 83%, after PDs in 85%, and after PPPH resections and draining procedures in 18% of cases. Diabetes mellitus developed thrice after PD. CONCLUSIONS PD is the main surgical option for PP treatment at present; early diagnosis makes PPDR the treatment of choice for PP; efficacy of PPDR for DD treatment provides proof that so-called PP is an entity of duodenal, but not "paraduodenal," origin.
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Affiliation(s)
- V. I. Egorov
- Department of Surgical Oncology, Moscow City Hospital No. 5, Sechenov First Moscow State Medical University, Stromynka Street 7, Moscow 107076, Russia
| | - A. N. Vankovich
- Hepatopancreatobiliary Department, Vishnevsky Institute of Surgery, Bolshaya Serpukhovskaya Street 27, Moscow 117997, Russia
| | - R. V. Petrov
- Department of Surgical Oncology, Moscow City Hospital No. 5, Sechenov First Moscow State Medical University, Stromynka Street 7, Moscow 107076, Russia
| | - N. S. Starostina
- Department of Surgical Oncology, Moscow City Hospital No. 5, Sechenov First Moscow State Medical University, Stromynka Street 7, Moscow 107076, Russia
| | - A. Ts. Butkevich
- General Surgery Department, Central Hospital of FSS RF, Petrovskoye Schosse 48, Golitsino, Moscow 143040, Russia
| | - A. V. Sazhin
- General Surgery Department, Moscow City Hospital No. 4, N. Pirogov Russian National Research Medical University, Ostrovityanova Street 1, Moscow 117513, Russia
| | - E. A. Stepanova
- Department of Pathology, Moscow City Hospital No. 12, Bakinskaya Street 26, Moscow 115516, Russia
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14
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Arora A, Dev A, Mukund A, Patidar Y, Bhatia V, Sarin SK. Paraduodenal pancreatitis. Clin Radiol 2013; 69:299-306. [PMID: 24094726 DOI: 10.1016/j.crad.2013.07.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Revised: 06/26/2013] [Accepted: 07/10/2013] [Indexed: 01/14/2023]
Abstract
Paraduodenal pancreatitis is a distinct clinicopathological entity involving the duodenum and the pancreatic tissue in the vicinity of the minor papilla. Most afflicted patients are young alcoholic males who present clinically with upper abdominal pain, weight loss, nausea, and vomiting. Pancreatic tissue elements in the duodenal wall and impedance to exocrine pancreatic secretions at the minor papilla are key factors in the pathogenesis of this condition. On imaging, the condition may manifest as a solid fibrotic mass around the minor papilla or as cysts in the duodenum and the pancreaticoduodenal groove. Duodenal stenosis, biliary strictures, chronic calcifying pancreatitis, and pancreatic ductal dilatation are also often observed.
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Affiliation(s)
- A Arora
- Department of Radiology, Institute of Liver and Biliary Sciences, Delhi, India.
| | - A Dev
- Department of Radiology, Institute of Liver and Biliary Sciences, Delhi, India
| | - A Mukund
- Department of Radiology, Institute of Liver and Biliary Sciences, Delhi, India
| | - Y Patidar
- Department of Radiology, Institute of Liver and Biliary Sciences, Delhi, India
| | - V Bhatia
- Department of Hepatology and Gastroenterology, Institute of Liver and Biliary Sciences, Delhi, India
| | - S K Sarin
- Department of Hepatology and Gastroenterology, Institute of Liver and Biliary Sciences, Delhi, India
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Fléjou JF. Paraduodenal pancreatitis: a new unifying term and its morphological characteristics. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/j.mpdhp.2011.10.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Pezzilli R, Santini D, Calculli L, Casadei R, Morselli-Labate AM, Imbrogno A, Fabbri D, Taffurelli G, Ricci C, Corinaldesi R. Cystic dystrophy of the duodenal wall is not always associated with chronic pancreatitis. World J Gastroenterol 2011; 17:4349-64. [PMID: 22110260 PMCID: PMC3218148 DOI: 10.3748/wjg.v17.i39.4349] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2011] [Revised: 03/31/2011] [Accepted: 04/07/2011] [Indexed: 02/06/2023] Open
Abstract
Cystic dystrophy of the duodenal wall is a rare form of the disease which was described in 1970 by French authors who reported the presence of focal pancreatic disease localized in an area comprising the C-loop of the duodenum and the head of the pancreas. German authors have defined this area as a “groove”. We report our recent experience on cystic dystrophy of the paraduodenal space and systematically review the data in the literature regarding the alterations of this space. A MEDLINE search of papers published between 1966 and 2010 was carried out and 59 papers were considered for the present study; there were 19 cohort studies and 40 case reports. The majority of patients having groove pancreatitis were middle aged. Mean age was significantly higher in patients having groove carcinoma. The diagnosis of cystic dystrophy of the duodenal wall can now be assessed by multidetector computer tomography, magnetic resonance imaging and endoscopic ultrasonography. These latter two techniques may also add more information on the involvement of the remaining pancreatic gland not involved by the duodenal malformation and they may help in differentiating “groove pancreatitis” from “groove adenocarcinoma”. In conclusion, chronic pancreatitis involving the entire pancreatic gland was present in half of the patients with cystic dystrophy of the duodenal wall and, in the majority of them, the pancreatitis had calcifications.
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Brotons A, Pico MD, Sola-Vera J, Sillero C, Cuesta A, Oliver I. Gastrointestinal Hemorrhage Secondary to Duodenal Cystic Dystrophy in Heterotopic Pancreas. Gastroenterology Res 2011; 4:30-33. [PMID: 27957010 PMCID: PMC5139798 DOI: 10.4021/gr257w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/22/2010] [Indexed: 12/19/2022] Open
Abstract
Cystic dystrophy of the duodenal wall (CDDW) is a complication of heterotopic pancreatic tissue located in the wall of the gastrointestinal tract, characterized by the presence of multiple small cysts, usually found in the wall of the second part of the duodenum. Gastrointestinal hemorrhage due to CDDW is a rare complication. We report the case of a 50-year-old man who was admitted to our hospital for persistent vomiting. The imaging tests confirmed the diagnosis of CDDW. During his stay in hospital, the patient had a gastrointestinal hemorrhage secondary to this disorder, which made it necessary to perform a Roux-en-Y gastrojejunostomy (Billroth III).
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Affiliation(s)
- Alicia Brotons
- Department of Gastroenterology, Hospital General Universitario de Elche, Alicante, Spain
| | - Maria Dolores Pico
- Department of Gastroenterology, Hospital General Universitario de Elche, Alicante, Spain
| | - Javier Sola-Vera
- Department of Gastroenterology, Hospital General Universitario de Elche, Alicante, Spain
| | - Carlos Sillero
- Department of Gastroenterology, Hospital General Universitario de Elche, Alicante, Spain
| | - Amador Cuesta
- Department of Gastroenterology, Hospital General Universitario de Elche, Alicante, Spain
| | - Israel Oliver
- Department of Surgery, Hospital General Universitario de Elche, Alicante, Spain
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Casetti L, Bassi C, Salvia R, Butturini G, Graziani R, Falconi M, Frulloni L, Crippa S, Zamboni G, Pederzoli P. "Paraduodenal" pancreatitis: results of surgery on 58 consecutives patients from a single institution. World J Surg 2010; 33:2664-9. [PMID: 19809849 DOI: 10.1007/s00268-009-0238-5] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Cystic dystrophy of heterotopic pancreas, groove pancreatitis, pancreatic hamartoma of the duodenum, paraduodenal wall cyst, and myoadenomatosis are all terms grouped together, from a pathological viewpoint, as definitions of paraduodenal pancreatitis (PP). The objective of the present study was to investigate the clinical characteristics, therapeutic strategies, and results in 58 patients undergoing pancreatic resection for PP. METHODS From January 1990 to December 2006 data were prospectively collected on 58 patients who were diagnosed with PP who then underwent pancreaticoduodenectomy. RESULTS In this patient cohort the median age was 44.7 years; only 4 patients were women, and only 3 had non-drinker and/or non smoker habits. The overall morbidity was 18.9%, and the median hospitalization was 11 days. There were no postoperative deaths. In a median follow-up of 96.3 months, all patients noted a decrease in the pain associated with PP; 35 patients (76%) had complete disappearance of pain, whereas occasional relapsing pain occurred in the remaining 11 (24%). CONCLUSIONS Patients with PP have clinical characteristics similar to those of chronic pancreatitis. The diagnostic imaging modalities of choice are ultrasonographic endoscopy and magnetic resonance cholangiopancreaticography. Based on our surgical experience, pancreaticoduodenectomy seems to be a reasonable choice of treatment in patients with PP.
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Affiliation(s)
- L Casetti
- Dipartimento di Scienze Chirurgiche, University of Verona, Policlinico GB Rossi, Piazzale LA Scuro, 37134 Verona, Italy
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Yoshida N, Nakayama H, Hemmi A, Suzuki T, Takayama T. Duodenal stenosis caused by cystic dystrophy in heterotopic pancreas: report of a case. Surg Today 2009; 39:803-6. [PMID: 19779779 DOI: 10.1007/s00595-009-3939-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2008] [Accepted: 01/07/2009] [Indexed: 12/14/2022]
Abstract
We herein describe the first reported case of duodenal stenosis caused by cystic dystrophy in heterotopic pancreas (CDHP) in Asia. A 63-year-old man was admitted to the hospital presenting with nausea and vomiting of 2 days' duration. Laboratory examinations showed an elevation in both the serum amylase level (275 IU/l) and white blood cell count (13 600/microl). A 3-cm-diameter tumor close against the duodenum was pointed out from the results of computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP); the tumor contained a cystic and solid component. Endoscopic examinations and an upper gastrointestinal series showed stenosis of the second portion of the duodenum without any mucosal change. The tumor was considered to be located at the submucosal layer of the second duodenum. The biopsy specimen of the duodenum revealed no malignancy. We strongly doubted the presence of a malignant submucosal tumor in the duodenum based on the findings of diagnostic imaging, and a pancreaticoduodenectomy was thus performed. Histopathologically, the lesion was diagnosed to be CDHP. The postoperative course was uneventful. The patient was symptomatic but was free of any symptoms after surgery. He continues to be regularly followed up on an outpatient basis and has had no recurrence of symptoms. This case demonstrates the need to consider CDHP in the differential diagnosis as a rare cause of duodenal stenosis.
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Affiliation(s)
- Nao Yoshida
- Department of Digestive Surgery, Nihon University School of Medicine, Tokyo 173-8610, Japan
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20
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Frulloni L, Gabbrielli A, Pezzilli R, Zerbi A, Cavestro GM, Marotta F, Falconi M, Gaia E, Uomo G, Maringhini A, Mutignani M, Maisonneuve P, Di Carlo V, Cavallini G. Chronic pancreatitis: report from a multicenter Italian survey (PanCroInfAISP) on 893 patients. Dig Liver Dis 2009; 41:311-317. [PMID: 19097829 DOI: 10.1016/j.dld.2008.07.316] [Citation(s) in RCA: 108] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2008] [Revised: 07/22/2008] [Accepted: 07/25/2008] [Indexed: 02/07/2023]
Abstract
BACKGROUND No data on chronic pancreatitis in Italy are available yet. AIM To evaluate demographic, clinical, diagnostic and therapeutic aspects in patients suffering from chronic pancreatitis. PATIENTS AND METHODS Eligible patients were prospectively enrolled from 2000 to 2005. Information concerning demographic data, lifestyle risk factors, family and clinical history, associated factors (alcohol, autoimmunity, cystic dystrophy of the duodenal wall, obstruction, genetic mutations) concomitant diseases, diagnostic findings, and pharmacological, endoscopic and surgical therapy were gathered. RESULTS 893 patients (74% males, mean age 53.7+/-15.2 years) were evaluated. 519/859 patients (60%) were drinkers and 555/840 (66%) were smokers. A strong positive correlation between drinking and cigarette consumption (R=0.53; p<0.0001) was found. Heavy alcohol consumption (>80g of alcohol/day for more than 5 years) was considered the most important risk factor in 300 patients (34%), obstruction in 238 (27%), alcohol and obstruction in 82 (9%), autoimmunity in 34 (4%), cystic dystrophy of the duodenal wall/groove pancreatitis in 55 (6%), gene mutations in 36 (4%), and none (idiopathic) in 148 (17%). Bile stones were diagnosed in 287 patients (33%) and cholecystectomy was performed in 329 patients (38%). Pancreatic calcifications were diagnosed in 547/879 patients (62%). Pancreatic surgery was performed in 273 patients (31%). Endoscopic sphincterotomy was performed in 371 patients (42%). Exocrine and endocrine insufficiency were found, respectively, in 373/834 (45%) and 275/885 patients (31%). CONCLUSIONS An unexpected low frequency of alcohol abuse and new emerging associated risk factors for chronic pancreatitis were observed in Italy.
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Affiliation(s)
- L Frulloni
- Department of Biomedical and Surgical Sciences, University of Verona, Verona, Italy.
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21
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Zamboni G, Capelli P, Scarpa A, Bogina G, Pesci A, Brunello E, Klöppel G. Nonneoplastic mimickers of pancreatic neoplasms. Arch Pathol Lab Med 2009; 133:439-53. [PMID: 19260749 DOI: 10.5858/133.3.439] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2008] [Indexed: 11/06/2022]
Abstract
CONTEXT A variety of nonneoplastic conditions may form pancreatic masses that mimic carcinoma. Approximately 5% to 10% of pancreatectomies performed with the clinical diagnosis of pancreatic cancer prove on microscopic evaluation to be pseudotumors. OBJECTIVES To illustrate the clinical and pathologic characteristics of the 2 most frequent pseudotumoral inflammatory conditions, autoimmune pancreatitis and paraduodenal pancreatitis, and describe the criteria that may be useful in the differential diagnosis versus pancreatic carcinoma. DATA SOURCES Recent literature and the authors' experience with the clinical and pathologic characteristics of autoimmune pancreatitis and paraduodenal pancreatitis. CONCLUSIONS The knowledge of the clinical, radiologic, and pathologic findings in both autoimmune pancreatitis and paraduodenal pancreatitis is crucial in making the correct preoperative diagnosis. Autoimmune pancreatitis, which occurs in isolated or syndromic forms, is characterized by a distinctive fibroinflammatory process that can either be limited to the pancreas or extend to the biliary tree. Its correct preoperative identification on biopsy material with ancillary immunohistochemical detection of dense immunoglobulin G4-positive plasma cell infiltration is possible and crucial to prevent major surgery and to treat these patients with steroid therapy. Paraduodenal pancreatitis is a special form of chronic pancreatitis that affects young males with a history of alcohol abuse and predominantly involves the duodenal wall in the region of the minor papilla. Pathogenetically, the anatomical and/or functional obstruction of the papilla minor, resulting from an incomplete involution of the intraduodenal dorsal pancreas, associated with alcohol abuse represents the key factor. Endoscopic drainage of the papilla minor, with decompression of the intraduodenal and dorsal pancreas, might be considered in these patients.
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Affiliation(s)
- Giuseppe Zamboni
- Department of Pathology, University of Verona, Ospedale Sacro Cuore-Don Calabria, Via don Sempreboni 5, 37024 Negrar-Verona, Italy.
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Triantopoulou C, Dervenis C, Giannakou N, Papailiou J, Prassopoulos P. Groove pancreatitis: a diagnostic challenge. Eur Radiol 2009; 19:1736-43. [PMID: 19238393 DOI: 10.1007/s00330-009-1332-7] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2008] [Revised: 12/19/2008] [Accepted: 12/29/2008] [Indexed: 02/07/2023]
Abstract
Groove pancreatitis is a distinct form of chronic pancreatitis characterized by inflammation and fibrous tissue formation, affecting the groove area between the head of the pancreas, the duodenum and the common bile duct. It is manifested on imaging by a sheet-like mass in the groove area near the minor papilla. Thickening of the duodenal wall and cystic transformation in the duodenal wall also represent common imaging features. Pathogenesis is still unclear, and clinical presentation is not specific. Endoscopic ultrasonography (EUS), computed tomography (CT) and magnetic resonance imaging (MRI) demonstrate imaging findings consistent with the disease in typical cases, but specific diagnosis is challenging in a number of patients where biopsy is required. The disease may mimic pancreatic, common bile duct or duodenal wall cancer that requires prompt and excessive surgical intervention, as opposed to groove pancreatitis where initial conservative treatment is suggested. The clinical, histopathological and radiological features on cross-sectional imaging of this entity are discussed in this review, and differential diagnostic clues are given.
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Affiliation(s)
- C Triantopoulou
- Computed Tomography Department, Konstantopouleion Agia Olga General Hospital, Athens, Greece.
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Guarise A, Faccioli N, Morana G, Megibow AJ. Chronic Pancreatitis vs Pancreatic Tumors. ACTA ACUST UNITED AC 2009. [DOI: 10.1007/978-3-540-68251-6_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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25
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Oh JY, Nam KJ, Choi JC, Cho JH, Yoon SK, Choi SS, Kwon HJ, Yoon JH, Kim SJ. Benign submucosal lesions of the stomach and duodenum: Imaging characteristics with endoscopic and pathologic correlation. Eur J Radiol 2008; 67:112-24. [PMID: 17720347 DOI: 10.1016/j.ejrad.2007.06.033] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2007] [Revised: 06/08/2007] [Accepted: 06/29/2007] [Indexed: 01/07/2023]
Abstract
Benign submucosal lesions of the stomach and duodenum are occasionally encountered during endoscopy. But endoscopy has its limitations in the diagnosis and differentiation of these lesions, because submucosal lesions are often difficult to visualize at endoscopy due to minimal change of the overlying mucosa. Furthermore, endoscopic biopsy may not always yield adequate tissue for diagnosis due to the submucosal location of the lesions. For this reason, the role of radiologic imaging is important in the diagnosis of submucosal lesions of the stomach and duodenum. Recent advances in computed tomography (CT) and sonographic technology are helpful in narrowing the differential diagnosis of gastroduodenal submucosal lesions. In contrast to endoscopy and barium studies, CT or ultrasonography (US) provides information about both the gastric wall and the extragastric extent of the disease. Arterial phase contrast enhanced CT enables us to discriminate a mass of submucosal from that of a mucosal origin in the differential diagnosis of gastric or duodenal lesions. Although endoscopic sonography has been considered the better modality in the diagnosis of gastroduodenal submucosal lesions, transabdominal sonography can still be an alternative method to endoscopic sonography in assessing of the origin and character of the submucosal lesions. Some gastroduodenal submucosal lesions have similar radiologic findings that make differentiation difficult. But despite overlaps in radiologic findings, some lesions have characteristic radiologic features that may suggest a specific diagnosis. Knowledge of the differential diagnosis of benign submucosal lesions in the stomach and duodenum may promote correct diagnosis and appropriate treatment.
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Affiliation(s)
- Jong Young Oh
- Department of Diagnostic Radiology, Dong-A University College of Medicine, Busan, Republic of Korea.
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26
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Martínez-Noguera A, D'Onofrio M. Ultrasonography of the pancreas. 1. Conventional imaging. ACTA ACUST UNITED AC 2007; 32:136-49. [PMID: 16897275 DOI: 10.1007/s00261-006-9079-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Ultrasound imaging has made significant advances in recent years and plays an important role in the detection, characterization and staging of pancreatic diseases. Conventional ultrasonography (US) is a noninvasive imaging modality, which continues to be the first diagnostic step in the evaluation of the pancreas. Over its various decades of application, US have detected pancreatic pathology of great diversity. This article reviews the wide utility of US and the many examinations techniques, such as filling the stomach with water, changing the patient's position or suspending inspiration or expiration, allowing us to visualize all portions of the pancreas in a high percentage of patients.
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Affiliation(s)
- A Martínez-Noguera
- Department of Radiology, Hospital Sant Pau, Autonomous University of Barcelona, Sant Antoni M. Claret 167, 08025 Barcelona, Spain.
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Rebours V, Lévy P, Vullierme MP, Couvelard A, O'Toole D, Aubert A, Palazzo L, Sauvanet A, Hammel P, Maire F, Ponsot P, Ruszniewski P. Clinical and morphological features of duodenal cystic dystrophy in heterotopic pancreas. Am J Gastroenterol 2007; 102:871-9. [PMID: 17324133 DOI: 10.1111/j.1572-0241.2007.01091.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Cystic dystrophy in heterotopic pancreas (CDHP) is an uncommon complication of pancreatic heterotopia, only described in surgical series, whose natural history is not known. The aim of this study was to determine clinical and morphological features of CDHP in a medical-surgical series of patients and to ascertain the relationship of CDHP with chronic pancreatitis (CP) in the pancreas proper. METHODS All patients who had duodenal CDHP diagnosed radiologically both with CT scan and endoscopic ultrasonography between 1995 and 2004 were included. The diagnosis was confirmed by surgical specimens when available. RESULTS One hundred five patients were included (91% men, 86% chronic alcoholic) with a median follow-up of 15 months. The median age at first symptoms was 46 yr. CDHP was associated with CP in the pancreas proper in 71% of patients. Presenting symptoms were pancreatic pain (91%), severe weight loss (73%), acute pancreatitis (45%), vomiting (30%), steatorrhea (23%), diabetes mellitus (20%), jaundice (13%), and upper gastrointestinal hemorrhage (5%). Cysts were multiple in 75% (median 3). The median diameter of the largest cyst was 10 mm. Endoscopy was normal in 36% of patients and showed duodenal stenosis in 52% (complete 6%, incomplete 46%). Surgical treatment was necessary in only 27% of patients (Whipple procedure 16%). CONCLUSIONS CDHP may arise in patients with or without CP and with or without chronic alcoholism. Symptoms may be severe but warrant surgery in less than one-third of patients.
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Affiliation(s)
- Vinciane Rebours
- Pôle des Maladies de l'Appareil Digestif, Service de Gastroentérologie-Pancréatologie, Hôpital Beaujon, AP-HP, Clichy, France
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Abstract
Although cystic tumors of the pancreas are relatively rare, they constitute an increasingly important category. Advances in imaging and interventional techniques and the sharp drop in the mortality rate of pancreatic surgery have rendered pancreatic biopsies and resections commonplace specimens. Consequently, in the past two decades, the nature of many cystic tumors in this organ has been better characterized. The names of some existing entities were revised; for example, what was known as papillary-cystic tumor is now regarded as solid-pseudopapillary tumor. New entities, in particular, intraductal papillary mucinous neoplasm and its variants, such as oncocytic and intestinal subtypes were recognized. The importance of clinical and pathologic correlation in the evaluation of these lesions was appreciated, in particular, with regards to the multifocality of these lesions, their association with invasive carcinomas, and thus their 'preinvasive' nature. Consensus criteria for the distinction of these from the ordinary precursors of adenocarcinoma, the pancreatic intraepithelial neoplasia, were established. The definition of mucinous cystic neoplasms was refined; ovarian-like stroma has now become almost a requirement for the diagnosis of mucinous cystic neoplasia, and defined as such, the propensity of these tumors to occur in perimenopausal women became even more striking. The validity and clinical value of classifying the pancreatic cysts of mucinous type as adenoma, borderline, CIS and invasive have been established. Related to this, the importance of thorough sampling in accurate classification of these mucinous lesions was recognized. Greater accessibility of the pancreas afforded by improved invasive as well as noninvasive modalities has also increased the detection of otherwise clinically silent cystic tumors, which has led to the recognition of more innocuous entities such as acinar cell cystadenoma and squamoid cyst of pancreatic ducts. As the significance of the cystic lesions emerged, cystic forms of otherwise typically solid tumors were also better characterized. Thus, significant developments have taken place in the classification and our understanding of pancreatic cystic tumors in the past few years, and experience with these lesions is likely to grow exponentially in the coming years.
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Affiliation(s)
- N Volkan Adsay
- Department of Pathology, Harper Hospital and Karmanos Cancer Institute, Wayne State University, Detroit, MI, USA.
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Tison C, Regenet N, Meurette G, Mirallié E, Cassagnau E, Frampas E, Le Borgne J. Cystic dystrophy of the duodenal wall developing in heterotopic pancreas: report of 9 cases. Pancreas 2007; 34:152-6. [PMID: 17198198 DOI: 10.1097/01.mpa.0000246669.61246.08] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Cystic dystrophy in heterotopic pancreas (CDHP), an uncommon but serious complication of dilatation of the ectopic pancreatic ducts of heterotopic pancreatic tissue, occurs most often in the second part of the duodenum. This disorder is difficult to diagnose and raises various therapeutic questions. The aim of this study was to evaluate the most useful procedures for investigating suspected CDHP and to consider late results after surgical treatment by pancreaticoduodenectomy (PD). METHODS This retrospective study concerned 9 patients who developed CDHP of the duodenal wall during an 18-year period (1983-2001). All patients were symptomatic and underwent PD (no postoperative deaths). Clinical presentation, imaging findings, pathological features, and follow-up were analyzed. RESULTS All patients but one were male alcoholics (mean age, 48 years; range, 37-63 years). The clinical presentation was abdominal pain (n = 9) associated with vomiting (n = 6), jaundice (n = 2), and weight loss (n = 9). Upper endoscopy (n = 9) showed nonspecific inflammatory lesions with duodenal stenosis (n = 4). Retrospective analysis of computed tomographic findings (n = 9) studied specific signs of CDHP and nonspecific inflammatory changes in periduodenal space. Endoscopic ultrasonography (n = 4) and magnetic resonance cholangiopancreatography (n = 2) were the most useful investigations. Pathological findings in surgical specimens were multiple cysts located in the thickened duodenal wall (n = 9), ectopic pancreatic tissue (n = 7), fibrosis of the normal gland (n = 4), and adenocarcinoma in ectopic tissue (n = 1). During the follow-up period, 4 patients died 12, 16, 48, and 72 months after PD. The cause of death was independent of CDHP or PD, but related to persistent alcoholism in 2 cases involving chronic pancreatitis. In 1 case, the patient died of disseminated adenocarcinoma. The other 5 patients had a good result. CONCLUSION Endoscopic ultrasonography and magnetic resonance pancreatography are the most useful investigations for the diagnosis of CDHP. Pancreaticoduodenectomy is justified after failure of medical treatment or endoscopic drainage. Late results after PD are dependent on alcoholic consumption when CDHP is associated with chronic pancreatitis.
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Affiliation(s)
- Christine Tison
- Department of Digestive and Endocrine Surgery, Hôtel-Dieu, Nantes, France
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30
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Repiso A, Gómez-Rodríguez R, García-Vela A, Martínez-Chacón J, González de Frutos C, Pérez-Grueso MJ, Carrobles JM. [Cystic dystrophy of the duodenal wall. An underdiagnosed complication in aberrant pancreas]. GASTROENTEROLOGIA Y HEPATOLOGIA 2006; 29:345-8. [PMID: 16790184 DOI: 10.1157/13089717] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Cystic dystrophy of the duodenal wall is an uncommon complication of aberrant pancreas characterized by increased duodenal wall thickness associated with intraparietal cystic lesions. We present the case of a male patient with cystic dystrophy of the duodenal wall, which posed major diagnostic problems due to the difficulty of distinguishing this entity from tumors of the head of the pancreas. Echoendoscopy was useful in establishing the definitive diagnosis, allowing puncture-evacuation of the intracystic contents with resolution of obstructive symptoms.
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Affiliation(s)
- Alejandro Repiso
- Servicio de Aparato Digestivo, Hospital Virgen de la Salud, Toledo, Spain.
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31
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Jouannaud V, Coutarel P, Tossou H, Butel J, Vitte RL, Skinazi F, Blazquez M, Hagège H, Bories C, Rocher P, Belloula D, Latrive JP, Meurisse JJ, Eugène C, Dellion MP, Cadranel JF, Pariente A. Cystic dystrophy of the duodenal wall associated with chronic alcoholic pancreatitis. Clinical features, diagnostic procedures and therapeutic management in a retrospective multicenter series of 23 patients. ACTA ACUST UNITED AC 2006; 30:580-6. [PMID: 16733382 DOI: 10.1016/s0399-8320(06)73231-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
AIM OF THE STUDY The aim of this retrospective multicenter study was to collect data from patients with chronic alcoholic pancreatitis and cystic dystrophy of the duodenal wall in order to better understand the outcome after medical, endoscopic and/or surgical treatment. PATIENTS AND METHODS The data from medical records of 23 patients consecutively seen in ten primary referral centers from January 1990 to July 2004 were studied. Clinical, biological, and endoscopic features as well as imaging findings were recorded. Response to treatment was noted. RESULTS Twenty-three patients (20 men), aged 45 years (range: 30-66), with chronic alcohol intake, cystic dystrophy of the duodenal wall, and previously known (N=14) or simultaneously diagnosed (N=9) chronic pancreatitis were included. Symptoms most frequently encountered were abdominal pain (N=22) and weight loss (N=16). An abdominal ultrasound was available for 10 patients, abdominal computed tomography for 22, upper endoscopy for 18, and endoscopic ultrasonography for 22. Endoscopic ultrasonography enabled diagnosis of cystic dystrophy of the duodenal wall in 19/22 patients. Six patients were symptom-free after alcohol withdrawal. Seven patients received octreotide 200 to 400 microg per day, 5 of whom subsequently underwent surgery (71%). Fourteen patients out of 23 were operated on (61%), 11 of whom underwent pancreaticoduodenectomy and remained symptom-free for 47 months follow-up. Mean follow-up was 56 months (range: 2-78) for non surgical patients (39%) and 47 months (range: 12-108) for surgical patients (61%). CONCLUSION Cystic dystrophy of the duodenal wall complicating chronic alcoholic pancreatitis may be the revealing sign of pancreatitis. Endoscopic ultrasongraphy is the most reliable imaging method for diagnosis. Pancreaticoduodenectomy is the most frequently employed definitive treatment.
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Affiliation(s)
- Vincent Jouannaud
- Services d'Hépato-Gastroentérologie des Centres Hospitaliers Généraux de Creil
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Valls C. L’ictère nu : rôle du radiologue dans la prise en charge diagnostique et thérapeutique. ACTA ACUST UNITED AC 2006; 87:460-78. [PMID: 16691176 DOI: 10.1016/s0221-0363(06)74027-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The purpose of this article is to provide an update on imaging techniques for diagnosis and staging of clinical conditions leading to obstructive jaundice. Clinical and imaging findings of the most frequent diseases presenting as obstructive jaundice will be reviewed in order to optimize imaging strategies. Imaging and treatment strategies will be discussed in order to provide an optimal diagnosis and staging with the least invasive techniques in order to minimize complications in these patients.
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Affiliation(s)
- C Valls
- Service de Radiologie, Hôpital Universitaire de Bellvitge, Feixa Llarga, Sn 08907, Hospitalet de Llobregat, Barcelone, Espagne.
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Pessaux P, Lada P, Etienne S, Tuech JJ, Lermite E, Brehant O, Triau S, Arnaud JP. Duodenopancreatectomy for cystic dystrophy in heterotopic pancreas of the duodenal wall. ACTA ACUST UNITED AC 2006; 30:24-8. [PMID: 16514378 DOI: 10.1016/s0399-8320(06)73073-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
AIM OF THE STUDY Cystic dystrophy in heterotopic pancreas (CDHP) is rare. The aim of this study was to evaluate the diagnosis, management, and follow-up of the CDHP. PATIENTS AND METHODS Between August 1990 and March 2004, 12 patients with CDHP underwent a duodenopancreatectomy. The patients were retrospectively reviewed. RESULTS There were 11 men and 1 woman with a mean age of 42.4 years (range: 34-54 years). Nine patients (75%) were alcoholic and 8 patients had chronic pancreatitis. The diagnosis of CDHP was performed in 8 patients (66.6%) after the preoperative workup. Seven patient had a medical treatment with octreotid and endoscopic cystic ponction (N=3) or cystic fenestration (N=1). Recurrence of pain was noted after a mean period of 5 months. Three patients had recurrent acute pancreatitis. Duodenopancreatectomy was performed in all cases. The mortality and morbidity rate were respectively 8.3% (N=1) and 25% (N=3). Mean follow-up was 64 months (ranges: 6 - 158 months). One patient was seen 70 months later with epigastric pain and features of acute pancreatitis of the pancreatic stump due to anastomotic stenosis. The other patients were asymptomatic. CONCLUSIONS Diagnosis of CDHP is difficult. After failure of medical treatment, duodenopancreatectomy can be proposed.
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Adsay NV, Basturk O, Klimstra DS, Klöppel G. Pancreatic pseudotumors: non-neoplastic solid lesions of the pancreas that clinically mimic pancreas cancer. Semin Diagn Pathol 2005; 21:260-7. [PMID: 16273945 DOI: 10.1053/j.semdp.2005.07.003] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In the pancreas, a variety of non-neoplastic conditions may form solid masses that may mimic cancer. Up to 5% of pancreatectomies performed with the preoperative clinical diagnosis of carcinoma will prove to be non-neoplastic by pathologic examination, although this figure is decreasing with improved diagnostic modalities. Chronic inflammatory lesions are the leading cause of this phenomenon ("pseudotumoral pancreatitis"), and among these, autoimmune and paraduodenal pancreatitides (discussed separately in this issue) are most important. In this article, we will focus on the noninflammatory lesions that may form tumor-like lesions of the pancreas. Adenomyomatous hyperplasia of ampulla of Vater is a subtle lesion that is difficult to define; larger examples (>5 mm) have been found to be the cause of obstructive jaundice. Accessory (heterotopic) spleen may form a well-defined nodule within the tail of the pancreas and is typically mistaken for endocrine neoplasm. Lipomatous hypertrophy is the replacement of pancreatic tissue with mature adipose tissue that occasionally leads to moderate to marked enlargement of the pancreas. Hamartomas are very rare if the entity is defined strictly. They are characterized by irregularly arranged mature pancreatic elements admixed with stromal tissue. A cellular, spindle-cell variant with c-kit (CD117) expression is recognized. Pseudolymphoma forms well-defined nodules composed of hyperplastic lymphoid tissue. Rarely, foreign-body deposits, granulomatous inflammations (such as sarcoidosis or tuberculosis), and congenital lesions may form tumoral lesions. In conclusion, it is important to recognize the types of conditions that form pseudotumors in the pancreas so that they can be distinguished from ductal adenocarcinomas, especially clinically, but also pathologically. Nonspecific terms such as "inflammatory pseudotumor" ought to be avoided, and every attempt should be made to classify a "pseudotumor" into a more specific diagnostic category discussed above.
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Affiliation(s)
- N Volkan Adsay
- Karmanos Cancer Institute/Wayne State University, Detroit, Michigan, USA.
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35
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Adsay NV, Zamboni G. Paraduodenal pancreatitis: a clinico-pathologically distinct entity unifying "cystic dystrophy of heterotopic pancreas", "para-duodenal wall cyst", and "groove pancreatitis". Semin Diagn Pathol 2005; 21:247-54. [PMID: 16273943 DOI: 10.1053/j.semdp.2005.07.005] [Citation(s) in RCA: 136] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
A distinct form of chronic pancreatitis occurring predominantly in and around the duodenal wall (near the minor papilla) has been reported under various names, including cystic dystrophy of heterotopic pancreas, pancreatic hamartoma of duodenum, para-duodenal wall cyst, myoadenomatosis, and groove pancreatitis. Our experience with these lesions and the review of the literature show that these lesions have the following common characteristics: (1) The duodenal wall contains dilated ducts, some with inspissated secretions, and pseudocystic changes as well as adjacent stromal reactions including hypercellular granulation tissue, foreign-body type giant cell reaction engulfing mucoprotein material, and myofibroblastic proliferation. (2) Brunner's gland hyperplasia is typically present. (3) Dense myoid stromal proliferation, with intervening rounded lobules of pancreatic acinar tissue, creates a histologic picture reminiscent of "myoadenomatosis," "pancreatic hamartoma," or even leiomyoma in some cases. (4) Spillover of fibrosis into the adjacent pancreas and soft tissue occurs, especially in the "groove" area (between the pancreas, common bile duct and duodenum), including the region around the common bile duct. (5) Clinically, these lesions often mimic "pancreas cancer" or periampullary tumors, because of marked scarring as well as the ill-defined borders of the process. Patients with these findings are predominantly males, 40-50 years old, with a history of alcohol abuse. That the process is often centered in the region of minor papilla (and the adjacent pancreas) suggests that an anatomic variation of the ductal system may render this area particularly susceptible to the effects of alcoholic injury, and the myo-adenomatoid and cystic changes on the duodenal wall may in turn represent changes related to a localized recurrent pancreatitis. In conclusion, these clinicopathologic findings characterize a distinctive process that can be referred to as paraduodenal pancreatitis.
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Affiliation(s)
- N V Adsay
- Karmanos Cancer Institute/Wayne State University, Detroit, Michigan, USA.
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36
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Lubrano J, Scatton O, Schlesser C, Soubrane O. [Aberrant pancreas and duodenal diaphragm: an exceptional association]. ACTA ACUST UNITED AC 2005; 131:334-7. [PMID: 16310158 DOI: 10.1016/j.anchir.2005.10.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2005] [Accepted: 10/25/2005] [Indexed: 12/01/2022]
Abstract
Aberrant pancreas of the duodenal wall (APD) and duodenal diaphragm (DD) are two rare entities, which developed during duodenal embryogenesis. Occurrence, diagnosis and therapeutic approach of these lesions are different. Herein, we report the first case of this exceptional association in a man who had no symptoms. A surgical resection of both lesions was performed and the outcome was uneventful. Embryogenesis, morphological characteristics and treatment are discussed.
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Affiliation(s)
- J Lubrano
- Service de chirurgie digestive, hôpital Cochin, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
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37
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Adsay NV, Basturk O, Thirabanjasak D. Diagnostic features and differential diagnosis of autoimmune pancreatitis. Semin Diagn Pathol 2005; 22:309-17. [PMID: 16939059 DOI: 10.1053/j.semdp.2006.04.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
A clinically and pathologically distinct form of chronic pancreatitis is now widely recognized and has been designated variably as lymphoplasmacytic sclerosing pancreatitis, duct-destructive (duct-centric) pancreatitis or autoimmune pancreatitis. This entity is currently defined by a constellation of clinical and pathologic findings, including the lack of both conventional risk factors for pancreatitis, such as alcohol use and gallstones, and their hallmark pattern of injury, including calcifications and pseudocysts. Histologically, it is characterized by lymphoplasmacytic inflammation with abundant IgG4-positive plasma cells that exhibit an affinity for ducts as well as venules ("peri-venulitis," with or without frank vasculitis). Inflammation is often associated with sclerosis and expansion of periductal tissue. In some cases, fibroblastic activity is prominent and resembles "inflammatory pseudotumor" or is even misdiagnosed as "inflammatory myofibroblastic tumor." In what appears to be a distinct subset of this entity, intraepithelial granulocytic infiltrates may be seen. Well-developed examples are readily recognized; however, lesser ones may be difficult to distinguish from other forms of pancreatitis based on morphology alone. This type of pancreatitis is considered an autoimmune process. In about 15% to 20% of patients, the clinical stigmata of autoimmune conditions are present at the time of diagnosis, and in many others, discovered subsequently. The usual "lymphoplasmacytic sclerotic" type tends to be associated with Sjogren, whereas the "granulocytic" subset, with inflammatory bowel disease. Most patients present with a pancreatic head mass, often with an accompanying stricture of the distal common bile duct, which thus radiologically resembles "pancreas cancer." In fact, this entity accounts for more than a third of the cases of pseudotumoral pancreatitis (mass-forming inflammatory lesions that resemble carcinoma). Elevated serum IgG4 levels are characteristic and may be very helpful in the differential diagnosis from tumors and tumor-like lesions of the pancreas which seldom result in levels above 135 mg/dL. The mean age of the patients with this condition is in the mid-50s; the subset with granulocytic intraepithelial lesions seem to be younger (mid 40s). Despite the autoimmune association, males are afflicted as commonly as (if not more than) females. Following resection, emergence of new fibro-inflammatory lesions in the remaining pancreaticobiliary tree has been noted in some cases; however, the process typically responds to steroids. It is important to recognize the distinctive clinicopathologic features of this entity, so that it can be diagnosed accurately and managed appropriately.
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Affiliation(s)
- N Volkan Adsay
- Department of Pathology, The Karmanos Cancer Institute and Wayne State University School of Medicine, Detroit, Michigan, USA.
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38
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Verbeke CS, Menon KV, Chalmers AG, McMahon MJ. Re: heterotopic pancreatitis with obstruction of the major duodenal papilla. Pancreatology 2005; 5:595; author reply 596. [PMID: 16113593 DOI: 10.1159/000087503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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39
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40
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Affiliation(s)
- B Bessoud
- Service de radiologie générale et interventionnelle, Hôpital de Bicêtre, 78, rue du Général Leclerc, 94270 Le Kremlin-Bicêtre.
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41
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Chatelain D, Vibert E, Yzet T, Geslin G, Bartoli E, Manaouil D, Delcenserie R, Brevet M, Dupas JL, Regimbeau JM. Groove pancreatitis and pancreatic heterotopia in the minor duodenal papilla. Pancreas 2005; 30:e92-5. [PMID: 15841034 DOI: 10.1097/01.mpa.0000161885.79373.1d] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Groove pancreatitis is a rare form of segmental chronic pancreatitis that involves the anatomic space between the head of the pancreas, the duodenum, and the common bile duct. We report 2 cases of groove pancreatitis with pancreatic heterotopia in the minor papilla. Patients were a 44-year-old woman and a 47-year-old man. Both had a past history of alcohol consumption and presented with abdominal pain, vomiting, and weight loss caused by duodenal stenosis. Abdominal computed tomography revealed thickening of the duodenal wall and enlargement of the pancreatic head in both patients. In 1 patient, ultrasound endoscopy showed a dilated duct in the head of the pancreas. Pancreaticoduodenectomy was performed to rule out pancreatic adenocarcinoma and because of the severity of the symptoms. In both cases, gross and microscopic examinations showed fibrous scar of the groove area. The Santorini duct was dilated and contained protein plugs in both patients, with abscesses in 1 of them. In both cases, there were microscopic foci of heterotopic pancreas with mild fibrosis in the wall of the minor papilla. Groove pancreatitis is often diagnosed in middle-aged alcoholic men presenting with clinical symptoms caused by duodenal stenosis. The pathogenesis of this rare entity could be because of disturbance of the pancreatic secretion through the minor papilla. Pancreatitis in heterotopic pancreas located in the minor papilla and chronic consumption of alcohol seem to be important pathogenic factors.
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Affiliation(s)
- Denis Chatelain
- Department of Pathology, Centre Hospitalier Universitaire Amiens, Amiens, France.
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42
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Beaulieu S, Vitte RL, Le Corguille M, Petit Jean B, Eugène C. Traitement endoscopique de la dystrophie kystique de la paroi duodénale. ACTA ACUST UNITED AC 2004; 28:1159-64. [PMID: 15657542 DOI: 10.1016/s0399-8320(04)95198-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Optimal management of cystic dystrophy of a heterotopic duodenal pancreas or cystic dystrophy of the duodenal wall has not yet been established. Surgical treatment by pancreaticoduodenectomy or by-pass procedure is indicated in patients with the most serious symptoms. Endoscopic cystic drainage is an alternative to surgery. We report three cases of cystic dystrophy of the duodenal wall successfully treated by endoscopic drainage. Symptoms disappeared immediately in all cases. No complications were observed. In one case, a second drainage was necessary 15 months after the first one. The 3 patients were free of symptoms after 6, 36, and 44 months of follow-up, respectively. No recurrence was found with CT-scan. The long-term efficiency of the endoscopic procedure must to be evaluated.
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Affiliation(s)
- Sandrine Beaulieu
- Service d'Hépato-Gastroentérologie, Centre hospitalier intercommunal de Poissy, Saint-Germain-en-Laye, 10 rue du champ Gaillard, 78303 Poissy.
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Abstract
Lymphoplasmacytic sclerosing pancreatitis (LPSP), also known as autoimmune pancreatitis or nonalcoholic, duct destructive chronic pancreatitis, has been increasingly recognized in the past decade as a histologically distinctive type of pancreatitis that affects middle-aged patients who lack the typical risk factors for chronic pancreatitis (alcohol abuse in particular). LPSP is sometimes associated with other autoimmune diseases or fibroinflammatory lesions, although in some patients, pancreatic and biliary involvement represent the only known disease process. Many patients present with pancreatic masses clinically and radiographically simulating pancreatic carcinoma, and associated bile duct strictures enhance the resemblance. Elevated serum IgG4 levels have been described in patients with LPSP and have been used to distinguish LPSP from pancreatic carcinoma preoperatively. Although there is some heterogeneity of pathologic findings, resected cases of LPSP typically demonstrate dense periductal lymphoplasmacytic inflammation, periductal and parenchymal fibrosis, and obliterative venulitis; neutrophilic infiltration of the ductal epithelium ("granulocytic epithelial lesions") may also occur. Large tumor-like masses of fibroinflammatory tissue ("reactive fibroinflammatory pseudotumors") may develop and extend beyond the pancreas. Following surgical resection, a few patients suffer recurrence of fibroinflammatory lesions in the pancreatobiliary tree, or they may develop other manifestations of autoimmune disease elsewhere in the body. However, the overall prognosis is excellent. Response to steroid therapy has been noted. Current studies are focusing on identifying additional preoperative diagnostic tests and on characterizing possible variants of LPSP. This review presents the defining clinical and pathologic features of LPSP and discusses the ongoing efforts to understand the pathogenesis of this disease.
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Affiliation(s)
- David S Klimstra
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA.
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44
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Yu J, Fulcher AS, Turner MA, Halvorsen RA. Normal anatomy and disease processes of the pancreatoduodenal groove: imaging features. AJR Am J Roentgenol 2004; 183:839-46. [PMID: 15333380 DOI: 10.2214/ajr.183.3.1830839] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Jinxing Yu
- Department of Radiology, Abdominal Imaging Section, Virginia Commonwealth University, Medical College of Virginia Hospitals and Physicians, 1250 E Marshall St., PO Box 980615, Richmond, VA 23298-0615, USA.
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Jovanovic I, Knezevic S, Micev M, Krstic M. EUS mini probes in diagnosis of cystic dystrophy of duodenal wall in heterotopic pancreas: A case report. World J Gastroenterol 2004; 10:2609-12. [PMID: 15300920 PMCID: PMC4572177 DOI: 10.3748/wjg.v10.i17.2609] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Cystic dystrophy of the duodenal wall is a rare condition characterized by the development of cysts in heterotopic pancreatic tissue localized in the duodenal wall. A 38-year-old man was admitted to the hospital for abdominal pain and vomiting after food intake. The diagnosis of acute pancreatitis was initially suspected. Abdominal ultrasound examination revealed thickening of the second portion of duodenal wall within which, small cysts (diameter, less than 1 cm) were present in the vicinity of pancreatic head. The head of pancreas appeared enlarged (63 mm × 42 mm) and hypoechoic. Upper endoscopy and barium X-ray series were performed revealing a severe circumferential deformation, as well as 4 cm long stenosis of the second portion of the duodenum. CT examination revealed multiple cysts located in an enlarged, thickened duodenal wall with moderate to strong post-contrast enhancement. We suspected that patient had cystic dystrophy of duodenal wall developed in the heterotopic pancreas and diagnosis was confirmed by endoscopic ultrasound (EUS). Endoscopic ultrasound (EUS) revealed circular stenosis from the duodenal bulb onwards. A twenty megaHertz mini-probe examination further showed diffuse (intramural) infiltration of duodenal wall limited to the submucosa and muscularis propria of the second portion of duodenum with multiple microcysts within the thickened mucosa and submucosa. Patient was successfully surgically treated and pancreatoduodenectomy was performed. The pathological examination confirmed a diagnosis of cystic dystrophy of a heterotopic pancreas. Endoscopic ultrasonography features allow preoperative diagnosis of cystic dystrophy of a heterotopic pancreas in duodenal wall, with intraluminal 20 MHz mini probe sonography being more efficient in cases of luminal stenosis.
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Affiliation(s)
- Ivan Jovanovic
- Clinic of Gastroenterology and Hepatology, Clinical Center of Serbia, Belgrade, 6 Koste Todorovic, 11000 Belgrade, Serbia and Montenegro.
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Aubé C, Ridereau-Zins C, Croquet V, Pessaux P. Imagerie en coupes de l’estomac et du duodénum. ACTA ACUST UNITED AC 2004; 85:503-14. [PMID: 15184795 DOI: 10.1016/s0221-0363(04)97622-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Imaging of the stomach and duodenum provides an abundant semiology, which allows precise diagnosis. In this chapter we will review specific considerations related to CT, MRI and US imaging of the stomach and duodenum. Normal imaging features as well as the main gastric and duodenal diseases will be described and illustrated.
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Affiliation(s)
- C Aubé
- Services de Radiologie, CHU Angers.
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47
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Gabata T, Kadoya M, Terayama N, Sanada J, Kobayashi S, Matsui O. Groove pancreatic carcinomas: radiological and pathological findings. Eur Radiol 2003; 13:1679-84. [PMID: 12835985 DOI: 10.1007/s00330-002-1743-1] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2002] [Revised: 08/16/2002] [Accepted: 10/07/2002] [Indexed: 10/26/2022]
Abstract
The aim of this study was to clarify the characteristics of pancreatic head carcinomas mainly invading the groove between the duodenum and the pancreatic head. Nine patients with pathologically proven pancreatic head carcinomas underwent thin-slice dynamic CT, MR imaging, duodenal endoscopy, and angiography (seven patients). Plate-like masses within the groove region were seen in all cases, which showed hypointensity on T1-weighted images and slight hyperintensity on T2-weighted MR images. The masses appeared hypovascular in the early phase and delayed enhancement in the late phase of dynamic CT and MR imaging. On MR cholangiopancreatography, stenosis of intrapancreatic common bile duct was seen in all patients, whereas stenosis of the main pancreatic duct was seen in only three cases. Endoscopy revealed luminal narrowing of the duodenum in all patients, and duodenal mucosal biopsy demonstrated adenocarcinoma in seven patients. Abdominal arteriography showed serrated encasement of peripancreatic arteries in seven patients who received angiographic examinations. The CT and MR imaging findings of groove pancreatic carcinomas resemble those of groove pancreatitis. Differential diagnosis may be achieved by the pathological diagnosis of a biopsy specimen of the duodenal mucosa and arterial encasement on arteriography.
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Affiliation(s)
- Toshifumi Gabata
- Department of Radiology, Kanazawa University, School of Medicine, 13-1 Takara-machi, Kanazawa City 920-8641, Japan.
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48
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Sánchez Manuel J, Sáez-Royuela F, Seco Gil JL, Pérez Alvarez JC, De La Plaza Galindo M, López Morante AJ. [Acute recurring pancreatitis due to gastric duplication]. GASTROENTEROLOGIA Y HEPATOLOGIA 2002; 25:455-7. [PMID: 12139840 DOI: 10.1016/s0210-5705(02)70287-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
We report the case of a young female patient with a gastric duplication communicating with the pancreas, which manifested clinically as episodes of acute relapsing pancreatitis. We analyze the diagnostic procedures and treatment methods, and review similar cases reported in the literature.
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Affiliation(s)
- J Sánchez Manuel
- Servicio de Cirugía General, Hospital General Yagüe, Burgos, Spain
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49
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Vullierme MP, Vilgrain V, Fléjou JF, Zins M, O'Toole D, Ruszniewski P, Belghiti J, Menu Y. Cystic dystrophy of the duodenal wall in the heterotopic pancreas: radiopathological correlations. J Comput Assist Tomogr 2000; 24:635-43. [PMID: 10966201 DOI: 10.1097/00004728-200007000-00023] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE The purpose of this work was to correlate the CT features of cystic dystrophy in heterotopic pancreas (CDHP) with pathological features. METHODS Patients were selected from 190 patients who underwent pancreatico-duodenectomy over a 10 year period in our institution. CT findings were retrospectively analyzed in 20 cases and correlated with pathological findings. RESULTS Lesions were found to be located in the inner part of the second portion of the duodenum in all except one case. In all cases, the duodenal wall was thickened, both at CT and at histopathological examination, and moderate to strong contrast enhancement of the duodenal wall was noted at CT in all cases but one. Cysts were multiple in all cases. No heterotopic pancreas was identified with CT. Inflammatory changes with or without enlarged nodes were detected on CT in 15 of 20 cases. Chronic pancreatitis was present in 10 cases at pathology, including 5 cases with calcifications. The radiopathological correlation was excellent for all criteria but two: the size of the cysts and the extent of pyloric involvement. CONCLUSION In patients with CDHP, CT features correlate well with pathological results. Multiple cysts located in an enlarged duodenal wall with postcontrast enhancement and inflammatory changes are strongly suggestive of CDHP.
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Affiliation(s)
- M P Vullierme
- Department of Radiology, Hôpital Beaujon, Clichy, France
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50
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Falconi M, Valerio A, Caldiron E, Salvia R, Sartori N, Talamini G, Bassi C, Pederzoli P. Changes in pancreatic resection for chronic pancreatitis over 28 years in a single institution. Br J Surg 2000; 87:428-33. [PMID: 10759737 DOI: 10.1046/j.1365-2168.2000.01391.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Because of advances in knowledge over recent years there is reason to believe that surgical attitudes towards patients with chronic pancreatitis may have changed. METHODS Some 547 patients were treated surgically for chronic pancreatitis from 1971 to June 1998. Anastomoses were performed in 80 per cent (438 patients) and resections in 20 per cent (109 patients). Indications and type of operation were analysed, as were mortality and morbidity rates and long-term follow-up results, in patients undergoing resection both over the period as a whole and after dividing the series into two subperiods of 14 years. RESULTS In the second 14-year period, there was a significant reduction in the percentage of resections compared with anastomoses (28 per cent (69 of 244 patients) versus 13 per cent (40 of 303); P < 0.0001), and a significant change in the type of resection with a substantial increase in resections of the head compared with those of the body and tail. Statistically significant reductions occurred in operating times, number of units of blood transfused (mean(s.d.) 4.7(3.6) versus 1.2(1.6) units; P = 0.0001) and mean hospital stay (18 versus 14 days for pylorus-preserving and 12 versus 8 days for left pancreatectomy with splenectomy; P < 0. 01); mortality and morbidity rates also tended to decrease, but not significantly. CONCLUSION A different pattern has emerged over the years as regards both the type and number of resections performed.
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Affiliation(s)
- M Falconi
- Department of Surgery, Pancreatic Unit and Endoscopy Service, Verona University Hospital, Verona, Italy
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