Occult pancreatic head cancer in the setting of gallstone and common bile duct stones complicated by acute pancreatitis

Acute pancreatitis usually results from alcohol abuse or biliary obstruction [1], however, it can also result from pancreatic cancer [2]. The association between acute pancreatitis and pancreatic cancer has been reported [3], and the majority of these cases were initially misinterpreted as idiopathic pancreatitis. This is the first report describing a case of pancreatic cancer in the setting of biliary stones complicated by recurrent acute pancreatitis.

A 79-year-old woman presented with intermittent upper abdominal pain for 10 months. She had experienced an episode of acute pancreatitis 10 months previously, and gallstones were detected by trans-abdominal ultrasound; but she declined laparoscopic cholecystectomy. Seven months later, the abdominal pain recurred. Based on the symptoms, significantly elevated serum amylase, and computed tomography (CT) findings ([Fig. 1]), acute pancreatitis was diagnosed. Magnetic resonance imaging (MRI) revealed both common bile duct (CBD) stones ([Fig. 2 a]) and gallstones ([Fig. 2 b]). She underwent laparoscopic cholecystectomy uneventfully. She was later referred for CBD stone removal.

Her physical examination and laboratory findings were unremarkable. During endoscopic retrograde cholangiopancreatography, the papilla was examined and no obvious abnormality was found. Cholangiogram detected multiple filling defects, suggesting CBD stones. These stones were extracted completely ([Fig. 3]).

However, the patient complained of recurrent severe epigastric pain afterwards. An abdominal plain radiograph did not suggest duodenal perforation, and serum amylase was unremarkable. We proceeded with a CT scan, and it showed a pancreatic head hypodense mass ([Fig. 4 a]). Subsequent endoscopic ultrasound-guided fine-needle aspiration revealed pancreatic adenocarcinoma ([Fig. 4 b]).

Fig. 1 Computed tomography scan obtained during the third day from symptom onset showed peripancreatic fluid collection, suggestive of acute pancreatitis.

Fig. 2 Magnetic resonance imaging revealed the presence of both common bile duct stones (a) and gallstones (b).

Fig. 3 Uneventful stone extraction by Dormia basket.

Fig. 4  (a) Computed tomography scan revealed a hypodense mass lesion (white arrow) in the pancreatic head. (b) Cytological evidence of pancreatic cancer.

In the exudative phase of acute pancreatitis, the acute fluid collection and non-enhanced pancreatic parenchyma may obscure the appearance of pancreatic cancer; therefore, the initial mass could have been missed during initial CT due to the acute inflammatory changes. Therefore, when pancreatic cancer is suspected, CT scanning during the pancreatic parenchymal phase is quite important to detect the malignant lesions [4].

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References

• 1 Forsmark C E, Baillie J. AGA Institute Clinical Practice and Economics Committee; AGA Institute Governing Board. AGA Institute technical review on acute pancreatitis.  Gastroenterology. 2007;  132 2022-2044
• 2 Acute pancreatitis and pancreatic cancer. Biology, diagnosis, and therapy. Proceedings of the fourth meeting of the International Association of Pancreatology and the third meeting of the International Pancreatic Cancer Study Group; 1990 August 20  –23; Nagasaki City, Japan.  Int J Pancreatol. 1991;  9 1-172
• 3 Niccolini D G, Graham J H, Banks P A. Tumor-induced acute pancreatitis.  Gastroenterology. 1976;  71 142-145
• 4 Pancreatic Cancer.  In: Evans DB, Pisters PWT, Abbruzzese JL (eds). MD Anderson Solid Tumor Oncology Series.  New York; Springer-Verlag 2002