An 85-year-old woman was admitted with painless obstructive jaundice
that had developed over the previous few weeks. Ultrasound examination showed
intrahepatic and extrahepatic duct dilatation; the common bile duct (CBD)
measured 2.5 cm, and there was a suggestion of pancreatic duct
dilatation. A few gallstones were identified in an otherwise normal-looking
gallbladder, but no obstructing CBD stones were seen. The dilated biliary
system was confirmed by endoscopic retrograde cholangiopancreatography (ERCP);
no stones were identified in the CBD, but a copious amount of mucus was cleared
from the duct. A large gastric ulcer was also noted at ERCP, which was
confirmed on formal gastroduodenoscopy and was also seen to be secreting thick
mucus into the stomach ([Fig. 1]).
Fig. 1 Esophagogastroduodenoscopy showing a
large, mucus-secreting gastric ulcer.
A computed tomography (CT) scan showed a cystic pancreatic mass, and
on magnetic resonance cholangiopancreatography (MRCP) the dilated pancreatic
duct was seen to form a connection to the stomach ([Fig. 2]).
Fig. 2 Magnetic resonance
cholangiopancreatography (MRCP) showing: a the dilated
pancreatic duct that had formed a fistula; b the stomach
with the other end of the fistula.
Gastric ulcer biopsies showed fragments of a severely dysplastic
villous tumour, but biliary brushings were inconclusive. An endoscopic
ultrasound (EUS) with fine needle aspiration was performed, which confirmed the
eventual diagnosis of a mucinous cystadenoma of the pancreas with a fistulating
gastric metastasis.
There were extensive discussions with the patient and her daughter
about further treatment options, but clinically she had become very frail,
experiencing further bouts of cholangitis that required insertion of a metal
stent, so the multidisciplinary decision was for palliative management.
Differentiation of pancreatic cysts between benign and malignant
causes can be difficult, requiring a combination of clinical, radiological, and
histological approaches [1]. The fistula seen in this
case between the mucinous cystadenoma and the stomach wall represents a rare
finding, not being a previously reported feature of pancreatic cystic
neoplasms.
Endoscopy_UCTN_Code_CCL_1AB_2AD_3AC
