Introduction: Pancreatic serous cystadenomas (PSCA) which represent one-third of pancreatic cystic neoplasms are typically benign asymptomatic lesions usually found incidentally on imaging studies at the body or tail of the pancreas. When symptomatic, presents typically with abdominal pain and a palpable mass. We report a case with PSCA presented as chronic diarrhea due to pancreatic duct (PD) obstruction with further enlargement over the years leading to biliary and partial duodenal obstruction. Case Description/Methods: A 65-year-old man with chronic diarrhea and a remote history of Hodgkin's Lymphoma treated with Mantle and pelvic radiation. Initially diagnosed as radiation enteritis, presented to our clinic with worsening diarrhea, flatulence, bloating, and weight loss. Endoscopic evaluation was negative for celiac disease or microscopic colitis. Diarrhea responded to empiric trial of pancreatic enzymes and he regained weight. CT scan of abdomen done to determine the etiology of exocrine pancreatic insufficiency (EPI) revealed a 3.7 cm complex cystic mass in the in the head of the pancreas with PD dilation and atrophy of the body and tail (Figure). Endoscopic ultrasound showed pancreatic mass with involvement of SMA and portal vein. Fine needle aspiration was not diagnostic. CT-guided biopsy was consistent with PSCA. 4 years later he complained of pale stools and dark urine; labs revealed ALT 495, alkaline phosphatase 463, bilirubin 4.5. MRI showed cyst enlargement to 5.7 cm with biliary dilation. Surgical consultation deemed him not to be a surgical candidate because of radiation induced vascular disease. ERCP with fully covered stent placement led to resolution of symptoms and normalization of liver tests. A year later ERCP with stent exchange showed compression of the duodenum distal to the stent leading to partial obstruction. Discussion: PSCA is usually an incidental finding on imaging studies. EPI is most commonly a result of chronic pancreatitis. Our patient presented with chronic diarrhea due to EPI as a result of PD obstruction by a PSCA. This case underscores the importance of imaging the pancreas in all patients with EPI to evaluate for potential underlying neoplasm causing obstruction of the PD. Our case also highlights that PSCA although benign if in the head of the pancreas can grow in size leading to gastric outlet obstruction and obstructive jaundice which can be associated with significant morbidity if the patient is not a surgical candidate.[1694] Figure 1. There is an approximately 4.0 cm x 3.7 cm ill-defined complex mass in the head of the pancreas.
cholecystocutaneous fistulae with either laparoscopic or open cholecystectomies and fistulae resections have been described with good success. Cholecystocutaneous fistulae in the setting of gallbladder malignancy have poor outcomes due to the spread to adjacent structures. Improved imaging diagnosis of gallstone and gallbladder disease, antibiotic therapies, early surgical intervention for gallbladder disease, and endoscopic alleviation of biliary outflow obstructions have made such a presentation of cholecystocutaneous fistula a rarely seen phenomenon.[2811] Figure 1. A patient found to have cholecystocutaneous fistula with (A) gallbladder extruding from the abdominal wall, (B) occlusion cholangiogram post-removal of multiple common bile duct stones showing dilated CBD and cholelithiasis in an irregular, contracted gallbladder, and (C) CT scan showing a mass (star) with extrusion of gallbladder through the liver and skin (arrow).
Introduction: Plummer-Vinson Syndrome (PVS), also known as Paterson-Kelly syndrome, presents with a classic triad of dysphagia, iron-deficiency anemia and esophageal webs. Although this triad of disease is increasingly less prevalent, early detection and intervention are imperative to reduce mortality given increased risk of malignant transformation. 1 Case Description/Methods: A 22-year-old female with a history of iron deficiency anemia presented to the emergency department with syncope in the setting of palpitations and dyspnea. The patient endorsed alarm symptoms including hematochezia over the past 6 weeks, 20-lb unintentional weight loss and dysphagia. Initial labs were remarkable for a hemoglobin of 11.1 g/dL, and microcytic indices, with an MCV of 72.4 fL. The patient underwent esophagogastroduodenoscopy (EGD) to investigate the etiology of iron deficiency anemia. EGD revealed a prominent esophageal web (Figure A) in the proximal esophagus with associated erythema and mucosal friability. Significant narrowing impeded safe passage of the endoscope and thus serial pneumatic dilations to 10 mm were performed. Following pneumatic dilation, the endoscope was successfully advanced beyond the web (Figure B) to the gastroesophageal junction. The patient tolerated the procedure well and had immediate resolution of dysphagia following EGD with pneumatic dilation. She was then continued on iron supplementation as previously prescribed at discharge. Discussion: Plummer-Vinson Syndrome comprises the pathological triad of dysphagia, esophageal web, and iron deficiency anemia. Other signs and symptoms can include glossitis, angular cheilitis, and koilonychia. The decreased incidence of this syndrome parallels the decreased prevalence of iron deficiency in the developed world. Iron deficiency induces an iron-dependent enzyme dysfunction which causes oxidative stress, mucosal DNA damage and ultimately potentiates the formation of esophageal webs. 2 Without intervention, patients with this syndrome may develop absolute dysphagia, aspiration pneumonia and other complications. Due to increased risk of malignancy, surveillance EGDs are necessary to screen for esophageal carcinoma in patients with PVS.
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