Khneizer Gebran, Reddy Kavya M, Hammami Muhammad B, Alkaade Samer
Indiana University School of Medicine, Indianapolis, IN, USA.
Saint Louis University School of Medicine, St. Louis, MO, USA.
Gastroenterology Res. 2019 Feb;12(1):43-47. doi: 10.14740/gr1140. Epub 2019 Feb 26.
Intraductal papillary mucinous neoplasms (IPMN) of the pancreas are characterized by proliferation of mucin-secreting cells in the main pancreatic duct (PD) or its branches. The secreted thick mucin usually leads to PD obstruction and dilation. A common complication of IPMN is recurrent acute pancreatitis secondary to poor pancreatic fluid drainage, and rarely, pancreatobiliary and pancreatointestinal fistulae. We describe a unique case of IPMN in a 57-year-old male who was referred to our institution for evaluation of recurrent acute pancreatitis. After extensive evaluation, he was diagnosed with main duct IPMN. Intraductal PD biopsy revealed intestinal type IPMN with intermediate grade dysplasia. Patient was managed clinically by large caliber (10 French) PD stenting which eliminated his recurrent acute pancreatitis. The patient was initially referred for pancreatic resection; however, surgery was aborted and evaluated to be high risk with high morbidity secondary to the extensive adhesions between the pancreas and surrounding structures. Patient remained clinically stable for a few years except for an episode of acute pancreatitis that happened after a trial of stent removal. Subsequently, the patient did well after the PD stent was replaced. Recently, repeat abdominal imaging revealed a large pancreatoduodenal fistula which was confirmed on repeat endoscopic retrograde cholangiopancreatography. We were able to perform pancreatoscopy by advancing a regular upper scope through the fistula and into the PD. Interestingly, the fistula relieved the symptoms of obstruction and subsequently decreased the frequency of recurrent pancreatitis episodes with no further episodes at 6 months follow-up. This case highlights the importance of providing adequate PD drainage to reduce the frequency of recurrent acute pancreatitis in the setting of main duct IPMN, especially if the patient is not a surgical candidate. Also, physicians need to monitor for complications such as fistula formation between the pancreas and surrounding structures in the setting of chronic inflammation due to recurrent episodes of pancreatitis. Early identification of a fistula is important for surgical planning. Furthermore, since recent studies suggested a higher incidence of additional primary malignancies in patients with IPMN of the pancreas compared to the general population, patients may be considered for screening for other primary malignancies.
胰腺导管内乳头状黏液性肿瘤（IPMN）的特征是主胰管（PD）或其分支中分泌黏液的细胞增殖。分泌的浓稠黏液通常会导致胰管梗阻和扩张。IPMN的常见并发症是继发于胰液引流不畅的复发性急性胰腺炎，很少会出现胰胆瘘和胰肠瘘。我们描述了一例57岁男性的独特IPMN病例，该患者因复发性急性胰腺炎被转诊至我院进行评估。经过全面评估，他被诊断为主胰管IPMN。胰管内活检显示为伴有中度发育异常的肠型IPMN。患者通过大口径（10F）胰管支架置入进行临床治疗，这消除了他的复发性急性胰腺炎。该患者最初被转诊进行胰腺切除术；然而，手术中止，经评估因胰腺与周围结构之间广泛粘连而风险高、发病率高。除了在一次支架移除试验后发生的一次急性胰腺炎发作外，患者在几年内临床情况稳定。随后，更换胰管支架后患者情况良好。最近，重复腹部影像学检查发现一个大的胰十二指肠瘘，经重复内镜逆行胰胆管造影证实。我们通过将普通上消化道内镜经瘘管推进至胰管，成功进行了胰管镜检查。有趣的是，瘘管缓解了梗阻症状，随后降低了复发性胰腺炎发作的频率，在6个月的随访中未再发作。该病例强调了在主胰管IPMN情况下提供充分胰管引流以降低复发性急性胰腺炎频率的重要性，特别是如果患者不适合手术。此外，医生需要监测因复发性胰腺炎导致的慢性炎症情况下胰腺与周围结构之间瘘管形成等并发症。早期识别瘘管对于手术规划很重要。此外，由于最近的研究表明，与普通人群相比，胰腺IPMN患者发生其他原发性恶性肿瘤的发生率更高，因此可考虑对患者进行其他原发性恶性肿瘤的筛查。
