Chronic Pancreatitis Differential Diagnoses

  • Author: Jason L Huffman, MD; Chief Editor: Julian Katz, MD   more...
 
Updated: Mar 8, 2012
 
 

Diagnostic Considerations

Some patients with cystic neoplasms have undergone cyst-enteric anastomoses, only to develop malignancy later. Consider a cystic neoplasm in any patient without a clinical history of pancreatitis, even if no septa, solid component, or rim calcification is present on the imaging study.

While aspiration of the cyst fluid and measurement of its viscosity, carcinoembryonic antigen (CEA), cancer antigen (CA) 19-9, and other factors are helpful in differentiating the various types of cysts, surgical resection of the cyst is the standard of care in a good surgical candidate.

Groove pancreatitis is a unique form of segmental pancreatitis in which the inflammatory process is confined to the groove between the duodenum, common bile duct, and head of the pancreas, without necessarily involving the entire head of the pancreas.[6]

Differential Diagnoses

Proceed to Workup
 
 
Contributor Information and Disclosures
Author

Jason L Huffman, MD  Fellow, Department of Medicine, Division of Gastoenterology, Scott and White Healthcare, Texas A&M Health Science Center College of Medicine

Jason L Huffman, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, American Medical Association, American Society for Gastrointestinal Endoscopy, and Texas Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Kamil Obideen, MD  Assistant Professor of Medicine, Division of Digestive Diseases, Emory University School of Medicine; Consulting Staff, Division of Gastrointestinal Endoscopy, Atlanta Veterans Affairs Medical Center

Kamil Obideen, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Mohammad Wehbi, MD  Assistant Professor of Medicine, Associate Program Director, Department of Gastroenterology, Emory University School of Medicine; Section Chief of Gastroenterology, Atlanta Veterans Affairs Medical Center

Mohammad Wehbi, MD is a member of the following medical societies: American College of Physicians, American Gastroenterological Association, and American Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD  Clinical Professor of Medicine, Drexel University College of Medicine

Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law, Medicine & Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Additional Contributors

Tushar Patel, MB, ChB Professor of Medicine, Ohio State University Medical Center

Tushar Patel, MB, ChB is a member of the following medical societies: American Association for the Study of Liver Diseases and American Gastroenterological Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Reference Salary Employment

Noel Williams, MD Professor Emeritus, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Professor, Department of Internal Medicine, Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada

Noel Williams, MD is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Paul Yakshe, MD Assistant Professor of Medicine, University of Minnesota, Medical Director of Pancreas and Biliary Clinic, Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Fairview University Medical Center

Paul Yakshe, MD is a member of the following medical societies: American College of Gastroenterology, American Pancreatic Association, and American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

References

  1. Büchler MW, Martignoni ME, Friess H, Malfertheiner P. A proposal for a new clinical classification of chronic pancreatitis. BMC Gastroenterol. Dec 14 2009;9:93. [Medline]. [Full Text].

  2. Pezzilli R. Etiology of chronic pancreatitis: has it changed in the last decade?. World J Gastroenterol. Oct 14 2009;15(38):4737-40. [Medline]. [Full Text].

  3. Kawa S, Hamano H, Ozaki Y, et al. Long-term follow-up of autoimmune pancreatitis: characteristics of chronic disease and recurrence. Clin Gastroenterol Hepatol. Nov 2009;7(11 Suppl):S18-22. [Medline].

  4. Schmitt F, Le Henaff G, Piloquet H, et al. Hereditary pancreatitis in children: surgical implications with special regard to genetic background. J Pediatr Surg. Nov 2009;44(11):2078-82. [Medline].

  5. Ooi CY, Dorfman R, Cipolli M, et al. Type of CFTR mutation determines risk of pancreatitis in patients with cystic fibrosis. Gastroenterology. Jan 2011;140(1):153-61. [Medline].

  6. Tezuka K, Makino T, Hirai I, Kimura W. Groove pancreatitis. Dig Surg. 2010;27(2):149-52. [Medline].

  7. Saftoiu A, Popescu C, Cazacu S, et al. Power Doppler endoscopic ultrasonography for the differential diagnosis between pancreatic cancer and pseudotumoral chronic pancreatitis. J Ultrasound Med. Mar 2006;25(3):363-72. [Medline]. [Full Text].

  8. Kaufman M, Singh G, Das S, Concha-Parra R, Erber J, Micames C, et al. Efficacy of endoscopic ultrasound-guided celiac plexus block and celiac plexus neurolysis for managing abdominal pain associated with chronic pancreatitis and pancreatic cancer. J Clin Gastroenterol. Feb 2010;44(2):127-34. [Medline].

  9. Gadroy FX, Ponchon T, Roda R, et al. Endoscopic treatment of chronic pancreatitis: long-term results. Gastrointest Endosc. Apr 2006;63(5):AB312.

  10. Cahen DL, Gouma DJ, Nio Y, et al. Endoscopic versus surgical drainage of the pancreatic duct in chronic pancreatitis. N Engl J Med. Feb 15 2007;356(7):676-84. [Medline].

 
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This endoscopic retrograde cholangiopancreatography (ERCP) shows advanced chronic pancreatitis. The pancreatogram has blunting of the lateral branches, dilation of the main pancreatic duct, and filling defects consistent with pancreatolithiasis. The cholangiogram also shows a stenosis of the distal bile duct and a dilated biliary tree.
Chronic pancreatitis. Abdominal CT scan showing that a pancreatic pseudocyst is responsible for the distortion of the ductal system.
This patient has recurrent abdominal pain. She used alcohol heavily in the past and was involved in a motor vehicle accident. The pancreatogram shows subtle blunting of side branches consistent with chronic pancreatitis. A stricture also is present in the body of the pancreas where it drapes over the spine, probably resulting from the trauma she sustained in the motor vehicle accident. Air in the stomach makes it difficult to observe that contrast is filling a pseudocyst on the other side of the stricture. These findings are not amenable to endoscopic intervention, and the patient was sent for a distal pancreatectomy.
Chronic pancreatitis. This magnetic resonance cholangiopancreatography (MRCP) shows a healthy biliary system. The pancreatic ductal system is not well visualized. A subsequent endoscopic retrograde cholangiopancreatography (ERCP [not pictured]) showed pancreas divisum, with no evidence of a communication with the pseudocyst. The endoscopic features were ideal for an endoscopic transgastric pseudocystogastrostomy.
Chronic pancreatitis. CT scans of the abdomen following an endoscopic transgastric pseudocystogastrostomy. Note that 2 stents are placed through the stomach and into the pseudocyst. Before undertaking this type of endoscopic intervention, the endoscopist must be confident that a cystadenoma has not been mistaken for a pseudocyst.
Chronic pancreatitis. This patient had a persistent postoperative leak from the site of a distal pancreatectomy. In the mid-1990s, the author sought to facilitate enteric drainage using transpapillary stents placed into the pancreatic duct. While this changed the fluid dynamics in favor of healing the disrupted duct, some patients developed complications from this technique.
Chronic pancreatitis. The persistent postoperative leak from the site of a distal pancreatectomy has healed at 1-month follow-up (see the image above). However, after 4 weeks of transpapillary stenting, the pancreatogram now shows a stent-induced stenosis near the surgical genu (arrow). Based on this experience, the author stopped using pancreatic stents in this setting.
Chronic pancreatitis. This patient developed abdominal pain several weeks after being accidentally hit with a baseball bat. A CT scan showed a large splenic hematoma, and the patient underwent a splenectomy. His postoperative course was notable for recurrent pain, abdominal distension, and elevation of amylase levels over the course of 2-3 months. This repeat CT scan shows postsurgical changes in the left upper quadrant and a large fluid collection.
Chronic pancreatitis. The pancreatogram shows a small leak from the tail of the gland.
Chronic pancreatitis. A nasopancreatic tube courses through the esophagus, stomach, and duodenum and into the pancreatic duct. Externally, the end of the tube is attached to a suction bulb to decompress the ductal system and monitor its function on a daily basis. In contrast to patients treated with transpapillary stents, none of these patients ever has failed to return for a follow-up appointment. In addition, while stent obstruction and subsequent infection can occur with transpapillary stents, the author has not observed this complication while using nasopancreatic tubes.
Chronic pancreatitis. Nine days after placement of a nasopancreatic tube, a pancreatogram obtained via the tube showed that the disruption had healed (see the above image). The tube then was removed.
Chronic pancreatitis. This follow-up CT scan (see the above 2 images) shows a percutaneous tube in the left upper quadrant that was used to drain a fluid collection. It was removed after 4 weeks. The patient returned to work, regained his weight, and had no recurrence of abdominal pain or signs of a recurrent pancreatic leak.
Chronic pancreatitis. Pancreatogram in a patient with a pancreatic pseudocyst. Note how the pancreatic ducts are extrinsically distorted by a mass lesion.
This pancreatogram shows a pseudocyst communicating with the main pancreatic duct in a patient with chronic pancreatitis and recurrent abdominal pain. He was treated endoscopically with a transpapillary stent placed into the pancreatic duct.
Four weeks after placement of a transpapillary stent, a patient with a pseudocyst communicating with the main pancreatic duct (chronic pancreatitis with recurrent abdominal pain) had not had a recurrence of pain. The CT scan showed resolution of the cyst, and the follow-up pancreatogram showed marked improvement. Transpapillary stenting of the pancreatic duct should be reserved for patients with established chronic pancreatitis.
 
 
 
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