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An unusual case of giardia abscess in the pancreas diagnosed by endoscopic ultrasound (EUS)
AJG – September, Suppl., 2001
Case Summary: 24 y/o female with a past medical history significant for a cholecystectomy in 1997, presented with complaints of a constant, intense sharp diffuse abdominal pain for two years. She admitted to nausea and vomiting for a week prior to admission with fevers two to three days prior to admission. She noted a forty pound weight gain and denied melena, hematochezia, or change in bowel habits. She also noted dysphagia to solids but not to liquids. On exam she was febrile to 101.3 and was orthostatic. Her abdominal exam revealed a diffusely tender abdomen without hepatosplenomegaly, dullness to percussion, palpable masses, or bruits. Stool was negative for occult blood. Her initial laboratories revealed a microcytic anemia (Hemoglobin 11.8, MCV 63.2) and a bandemia of 11 without eosinophils. Computed tomography revealed a dilated second portion of the duodenum with infiltration of the retroperitoneal fat and multiple enlarged mesenteric lymph nodes, without evidence of retroperitoneal lymphadneopathy. The differential diagnosis at this time was lymphoma, tuberculosis, sarcoidosis, Crohn’s disease or eosinophilic gastroenteritis. She was confirmed to have an iron deficiency anemia. On the third hospital day an esophogastroduodenoscopy was performed to evaluate the thickened duodenum and biopsies were obtained. On the fifth hospital day, she developed an eosinophil count of six percent (absolute eosinophil count ⫽ 500). Her eosinophils reached a maximum of forty-four percent (absolute eosinophil count ⫽ 3600) on the ninth hospital day. The duodenal biopsy revealed duodenal mucosa with preserved villous architecture and focal increase in eosinophils. Therefore, she was diagnosis with eosinophilic gastroeneteritis. She still had nausea and abdominal pain and her computed tomography revealed a thickened duodenum. She was treated with 40mg of oral prednisone and her symptoms resolved with two weeks. Teaching Point: Although this patient did not have initial peripheral eosinophilia, she rapidly developed a profound peripheral eosinophilia during hospitalization, which resolved quickly with treatment.
664 An unusual case of giardia abscess in the pancreas diagnosed by endoscopic ultrasound (EUS) Syed F. Jafri, Raman Muthusamy, Kenneth J. Chang and Phuong T. Nguyen*. 1Gastrointestinal Oncology, University of California, Irvine, Orange, CA, United States. Purpose: Giardia in an intestinal pathogen that can rarely be found in the stomach in achlorohydric patients. We report the first case of an abscess in the pancreas due to giardia. Methods: 78 year old immunocompetent woman without significant past medical history, presented with nausea and fatigue of one year. She denied any abdominal pain, diarrhea, weight loss jaundice and recent travels. Her medications included a daily proton pump inhibitor and metoclopramide for nausea. Her laboratory data including liver function tests were unremarkable. Initial evaluation with upper endoscopy was negative. An abdominal CT revealed a 2 cm cystic lesion in the head of pancreas. An endoscopic retrograde cholangiopancreatography (ERCP) showed a normal pancreatic duct (PD) and a suspicion of an extrinisic compression of the distal common bile duct. Brushings obtained from the bile duct revealed benign cells and a biliary sphincterotomy was done with stent placement. On EUS there was no evidence of chronic pancreatitis and the PD was not dilated. A simple 1.5 ⫻ 1.4 cm round cyst was seen in the neck of the pancreas, with out continuity to the PD. EUS-guided fine needle aspiration performed on the cyst from the stomach revealed 2 cc’s of thick, whitishyellow, mucinous fluid. The cytology of this fluid showed numerous neutrophils, lymphocytes and to our surprise numerous GIARDIA organisms. The patient was subsequently treated with Metronidazole. Conclusions: To our knowledge this is the first case report of giardia abscess in the pancreas. Needle contamination from the intestinal wall was not possible, as the stomach is not a natural habitat for giardia. The large amount of organisms seen in the fluid ruled out the possibility of contamination and the presence of acute inflammatory cells also was consistent with an abscess cavity.
Abstracts
S209
665 Minor papilla extrapancreatic somatostatinoma-induced pancreatitis in pancreas divisum Sanjay B Jagannath1, Sergey V Kantsevoy1, Richard D Schulick2 and Marcia Irene F Canto1*. 1Gastroenterology, The Johns Hopkins Hospital, Baltimore, MD, United States; and 2Surgery, The Johns Hopkins Hospital, Baltimore, MD, United States. Purpose: A somatostatinoma (SSA) is a rare somatostatin-producing neuroendocrine tumor first described in the pancreas. The systemic effects of excess somatostatin lead to the classic presentation of the “Somatostatinoma Syndrome” (diabetes mellitus, cholelithiasis, steatorrhea). In contrast, extrapancreatic SSAs present with symptoms due to the local mass effect of the tumor. We report the first case of a SSA involving the minor papilla causing chronic pancreatitis (CP) in pancreas divisum (Pdiv). Methods: A 61 year-old female with a long history of smoking and alcohol and new-onset diabetes presented with an episode of acute pancreatitis. She had a 6-month history of recurrent epigastric tightness with radiation to her back. CT scan revealed a mildly dilated pancreatic duct and minimal enhancement of the pancreatic head. After an unsuccessful endoscopic retrograde cholangiopancreatography (ERCP), the patient was referred for further management. Results: An endoscopic ultrasound (EUS) revealed a poorly defined hypoechoic small mass in the pancreatic head with markedly heterogenous pancreatic parenchyma. The pancreatic duct was dilated to 4 mm in the head, and the papilla and the biliary tract appeared normal. Fine needle aspirate of the hypoechoic area did not reveal malignant cells. Given the concern over an undiagnosed malignancy, EUS was repeated four months later. The hypoechoic lesion in the pancreatic head had completely resolved, consistent with the clinical impression of focal pancreatitis. However, the main pancreatic duct was now dilated to 7 mm and the minor papilla was thickened and enlarged by a hypoechoic small mass limited to the duodenal wall. The pancreas had diffuse endosonographic features consistent with CP. ERCP showed a large, bulbous minor papilla, and opacification of the ventral and dorsal pancreatic ducts diagnosed Pdiv. A minor papillotomy with stent placement was performed. Biopsies of the open enlarged minor papilla revealed a SSA. The patient underwent an uncomplicated Whipple’procedure. Pathology showed an 8 mm malignant, well-differentiated SSA confined to the minor papilla, with 4/21 (⫹) lymph nodes. The patient has not had any evidence of tumor recurrence and denies further abdominal pain. Conclusions: Physicans must maintain a high degree of suspicion that focal obstruction from a tumor may be the cause of chronic pancreatitis. The SSA in this patient with pancreas divisum caused obstructive chronic pancreatitis due to its strategic location at the minor papilla. SSA cases of pure ampullary involvement are extremely rare, and this is the first published report of isolated minor papilla SSA associated with Pdiv and CP.
666 Needle-knife fistulotomy of the minor papilla: a novel approach for access to the dorsal pancreatic duct in a patient with pancreas divisum Sanjay B Jagannath1 and Anthony N Kalloo1*. 1Gastroenterology, The Johns Hopkins School of Medicine, Baltimore, MD, United States. Purpose: Pancreas divisum (Pdiv) is the most common pancreatic congenital anomaly, affecting an estimated 5–10% of the general population. The endoscopic management of clinically significant Pdiv involves minor papillotomy with stent placement. Unfortunately, cannulation of the dorsal pancreatic duct is associated with a relatively high failure rate. We describe a novel method to access the dorsal pancreatic duct when encountering a difficult cannulation in Pdiv. Methods: A 43 year-old woman with a remote history of choledocholithiasis treated previously with an endoscopic biliary sphincterotomy and cholecystectomy, presented with a 10-year history of recurrent pancreatitis. She described epigastric pain with radiation to the back and associated
Case Summary: 24 y/o female with a past medical history significant for a cholecystectomy in 1997, presented with complaints of a constant, intense sharp diffuse abdominal pain for two years. She admitted to nausea and vomiting for a week prior to admission with fevers two to three days prior to admission. She noted a forty pound weight gain and denied melena, hematochezia, or change in bowel habits. She also noted dysphagia to solids but not to liquids. On exam she was febrile to 101.3 and was orthostatic. Her abdominal exam revealed a diffusely tender abdomen without hepatosplenomegaly, dullness to percussion, palpable masses, or bruits. Stool was negative for occult blood. Her initial laboratories revealed a microcytic anemia (Hemoglobin 11.8, MCV 63.2) and a bandemia of 11 without eosinophils. Computed tomography revealed a dilated second portion of the duodenum with infiltration of the retroperitoneal fat and multiple enlarged mesenteric lymph nodes, without evidence of retroperitoneal lymphadneopathy. The differential diagnosis at this time was lymphoma, tuberculosis, sarcoidosis, Crohn’s disease or eosinophilic gastroenteritis. She was confirmed to have an iron deficiency anemia. On the third hospital day an esophogastroduodenoscopy was performed to evaluate the thickened duodenum and biopsies were obtained. On the fifth hospital day, she developed an eosinophil count of six percent (absolute eosinophil count ⫽ 500). Her eosinophils reached a maximum of forty-four percent (absolute eosinophil count ⫽ 3600) on the ninth hospital day. The duodenal biopsy revealed duodenal mucosa with preserved villous architecture and focal increase in eosinophils. Therefore, she was diagnosis with eosinophilic gastroeneteritis. She still had nausea and abdominal pain and her computed tomography revealed a thickened duodenum. She was treated with 40mg of oral prednisone and her symptoms resolved with two weeks. Teaching Point: Although this patient did not have initial peripheral eosinophilia, she rapidly developed a profound peripheral eosinophilia during hospitalization, which resolved quickly with treatment.
664 An unusual case of giardia abscess in the pancreas diagnosed by endoscopic ultrasound (EUS) Syed F. Jafri, Raman Muthusamy, Kenneth J. Chang and Phuong T. Nguyen*. 1Gastrointestinal Oncology, University of California, Irvine, Orange, CA, United States. Purpose: Giardia in an intestinal pathogen that can rarely be found in the stomach in achlorohydric patients. We report the first case of an abscess in the pancreas due to giardia. Methods: 78 year old immunocompetent woman without significant past medical history, presented with nausea and fatigue of one year. She denied any abdominal pain, diarrhea, weight loss jaundice and recent travels. Her medications included a daily proton pump inhibitor and metoclopramide for nausea. Her laboratory data including liver function tests were unremarkable. Initial evaluation with upper endoscopy was negative. An abdominal CT revealed a 2 cm cystic lesion in the head of pancreas. An endoscopic retrograde cholangiopancreatography (ERCP) showed a normal pancreatic duct (PD) and a suspicion of an extrinisic compression of the distal common bile duct. Brushings obtained from the bile duct revealed benign cells and a biliary sphincterotomy was done with stent placement. On EUS there was no evidence of chronic pancreatitis and the PD was not dilated. A simple 1.5 ⫻ 1.4 cm round cyst was seen in the neck of the pancreas, with out continuity to the PD. EUS-guided fine needle aspiration performed on the cyst from the stomach revealed 2 cc’s of thick, whitishyellow, mucinous fluid. The cytology of this fluid showed numerous neutrophils, lymphocytes and to our surprise numerous GIARDIA organisms. The patient was subsequently treated with Metronidazole. Conclusions: To our knowledge this is the first case report of giardia abscess in the pancreas. Needle contamination from the intestinal wall was not possible, as the stomach is not a natural habitat for giardia. The large amount of organisms seen in the fluid ruled out the possibility of contamination and the presence of acute inflammatory cells also was consistent with an abscess cavity.
Abstracts
S209
665 Minor papilla extrapancreatic somatostatinoma-induced pancreatitis in pancreas divisum Sanjay B Jagannath1, Sergey V Kantsevoy1, Richard D Schulick2 and Marcia Irene F Canto1*. 1Gastroenterology, The Johns Hopkins Hospital, Baltimore, MD, United States; and 2Surgery, The Johns Hopkins Hospital, Baltimore, MD, United States. Purpose: A somatostatinoma (SSA) is a rare somatostatin-producing neuroendocrine tumor first described in the pancreas. The systemic effects of excess somatostatin lead to the classic presentation of the “Somatostatinoma Syndrome” (diabetes mellitus, cholelithiasis, steatorrhea). In contrast, extrapancreatic SSAs present with symptoms due to the local mass effect of the tumor. We report the first case of a SSA involving the minor papilla causing chronic pancreatitis (CP) in pancreas divisum (Pdiv). Methods: A 61 year-old female with a long history of smoking and alcohol and new-onset diabetes presented with an episode of acute pancreatitis. She had a 6-month history of recurrent epigastric tightness with radiation to her back. CT scan revealed a mildly dilated pancreatic duct and minimal enhancement of the pancreatic head. After an unsuccessful endoscopic retrograde cholangiopancreatography (ERCP), the patient was referred for further management. Results: An endoscopic ultrasound (EUS) revealed a poorly defined hypoechoic small mass in the pancreatic head with markedly heterogenous pancreatic parenchyma. The pancreatic duct was dilated to 4 mm in the head, and the papilla and the biliary tract appeared normal. Fine needle aspirate of the hypoechoic area did not reveal malignant cells. Given the concern over an undiagnosed malignancy, EUS was repeated four months later. The hypoechoic lesion in the pancreatic head had completely resolved, consistent with the clinical impression of focal pancreatitis. However, the main pancreatic duct was now dilated to 7 mm and the minor papilla was thickened and enlarged by a hypoechoic small mass limited to the duodenal wall. The pancreas had diffuse endosonographic features consistent with CP. ERCP showed a large, bulbous minor papilla, and opacification of the ventral and dorsal pancreatic ducts diagnosed Pdiv. A minor papillotomy with stent placement was performed. Biopsies of the open enlarged minor papilla revealed a SSA. The patient underwent an uncomplicated Whipple’procedure. Pathology showed an 8 mm malignant, well-differentiated SSA confined to the minor papilla, with 4/21 (⫹) lymph nodes. The patient has not had any evidence of tumor recurrence and denies further abdominal pain. Conclusions: Physicans must maintain a high degree of suspicion that focal obstruction from a tumor may be the cause of chronic pancreatitis. The SSA in this patient with pancreas divisum caused obstructive chronic pancreatitis due to its strategic location at the minor papilla. SSA cases of pure ampullary involvement are extremely rare, and this is the first published report of isolated minor papilla SSA associated with Pdiv and CP.
666 Needle-knife fistulotomy of the minor papilla: a novel approach for access to the dorsal pancreatic duct in a patient with pancreas divisum Sanjay B Jagannath1 and Anthony N Kalloo1*. 1Gastroenterology, The Johns Hopkins School of Medicine, Baltimore, MD, United States. Purpose: Pancreas divisum (Pdiv) is the most common pancreatic congenital anomaly, affecting an estimated 5–10% of the general population. The endoscopic management of clinically significant Pdiv involves minor papillotomy with stent placement. Unfortunately, cannulation of the dorsal pancreatic duct is associated with a relatively high failure rate. We describe a novel method to access the dorsal pancreatic duct when encountering a difficult cannulation in Pdiv. Methods: A 43 year-old woman with a remote history of choledocholithiasis treated previously with an endoscopic biliary sphincterotomy and cholecystectomy, presented with a 10-year history of recurrent pancreatitis. She described epigastric pain with radiation to the back and associated