- Email: [email protected]
“Doctor, I have a long, sausage-shaped lump in my abdomen”
At the Focal Point
David Robbins, MD, MSc Assistant Editor for Focal Points
“Doctor, I have a long, sausage-shaped lump in my abdomen” An 88-year-old woman was admitted for postprandial epigastric pain, poor appetite, weight loss, and fever for the previwww.giejournal.org
ous 6 weeks. On physical examination, a tubular mass was palpable in the upper abdomen; although painful, the mass was Volume 75, No. 5 : 2012 GASTROINTESTINAL ENDOSCOPY 1100
At the Focal Point
nontender. Liver biochemical and pancreatic enzyme test results were normal. CT (A and B) demonstrated significant dilation (4 cm) of the entire main pancreatic duct (asterisk), with severe atrophy of the pancreatic parenchyma (small arrows). Neither pancreatic nor duodenal masses were documented, and no bile duct dilation was seen. ERCP revealed an enlarged major papilla orifice with spontaneous outflow of mucus (C). Pancreatography (D) confirmed significant dilation of the main pancreatic duct and showed it to be filled with mucus, which was removed by using an extraction balloon. Pancreatic ductal side branches were dilated mainly in the body and tail of the gland (arrows). No strictures were identified. The diagnosis of intraductal papillary mucinous neoplasm was proposed. A 7F, nasopancreatic drainage tube was placed for saline solution flushing of the duct, after which the abdominal mass did not substantially change in size, although the patient’s condition improved slightly after 3 days. The drain was removed, and the patient was discharged.
1101 GASTROINTESTINAL ENDOSCOPY Volume 75, No. 5 : 2012
Despite the fact that intraductal papillary mucinous neoplasm is a premalignant condition, surgery has not been scheduled for this patient because of her age and comorbid health conditions; clinical follow-up has been planned instead. DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Pietro Familiari, MD, PhD, Cristina Hervoso, MD, Ivo Boskoski, MD, Guido Costamagna, MD, Digestive Endoscopy Unit, Università Cattolica del Sacro Cuore, Gemelli University Hospital, Rome, Italy
doi:10.1016/j.gie.2012.01.018
www.giejournal.org
At the Focal Point
Commentary Intraductal papillary mucinous neoplasm (IPMN) first came to our attention in 1982 and now is an increasingly diagnosed entity that is well-recognized as a premalignant condition. Essentially, IPMN is a papillary neoplasm that arises from within the main pancreatic duct (there are variants that are confined to the side branches) and which produces large amounts of mucin that lead to chronic obstructive pancreatitis with ductal dilation. The involved ductal epithelium may demonstrate a range of histologic appearances from hyperplasia to dysplasia and carcinoma even within a single lesion. In recent series, malignant neoplasms account for a majority of IPMNs, most of which show invasive carcinoma at the time of diagnosis. As in this patient, most frequent symptoms of IPMN are abdominal pain and weight loss, not infrequently superimposed on a history of recurrent pancreatitis. The diagnosis is established by imaging studies, which typically reveal the dilated mucin-filled duct; ERCP shows a patulous ampulla with free-flowing mucus issuing from its os. As for the sausage here, this is just an extreme example of the degree to which a duct can dilate. The English humorist A.P. Herbert said, “A highbrow is one who looks at a sausage and thinks of Picasso.” For me, one who thinks of a dilated pancreatic duct when detecting what feels like a sausage in the abdomen, ah, now that’s an old-fashioned clinician. Lawrence J. Brandt, MD Associate Editor for Focal Points
Inverted diverticulum or adenomatous lesion? Identification using confocal laser endomicroscopy
A 59-year-old woman was seen for surveillance colonoscopy. She had no history of abdominal pain or rectal bleeding. Physical examination and results of laboratory investigations were unremarkable. High-resolution ileocolonoscopy revealed extensive diverticulosis in the sigmoid colon. Additionally, an 8-mm flat polyp with a central indentation and Kudo pit pattern II was found in the sigmoid colon (A). The polypoid structure showed no change in its appearance after air insufflation or palpation with biopsy forceps. To characterize the lesion more intensively, 5 mL of 10% fluorescein were administered intravenously, and the probe-based confocal laser endomicroscopy system (Cellvizio; Mauna Kea Technologies, Paris, France) was inserted through the working channel of the endoscope and gently pushed against the polypoid structure. Fluoresceinguided endomicroscopy revealed tubular architecture and nondysplastic cells (B). The polyp was removed by snare polypectomy, and the in vivo diagnosis of tubular adenoma without
www.giejournal.org
high-grade intraepithelial neoplasia was confirmed on histopathological analysis (C). DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Helmut Neumann, MD, PhD, Department of Medicine I, University of Erlangen-Nuremberg, Erlangen, Germany, Michael Vieth, MD, PhD, Institute of Pathology, Klinikum Bayreuth, Bayreuth, Germany, Raja Atreya, MD, PhD, Thomas Bernatik, MD, PhD, Jonas Mudter, MD, PhD, Markus F. Neurath, MD, PhD, Department of Medicine I, University of ErlangenNuremberg, Erlangen, Germany doi:10.1016/j.gie.2011.12.033
Volume 75, No. 5 : 2012 GASTROINTESTINAL ENDOSCOPY 1102
David Robbins, MD, MSc Assistant Editor for Focal Points
“Doctor, I have a long, sausage-shaped lump in my abdomen” An 88-year-old woman was admitted for postprandial epigastric pain, poor appetite, weight loss, and fever for the previwww.giejournal.org
ous 6 weeks. On physical examination, a tubular mass was palpable in the upper abdomen; although painful, the mass was Volume 75, No. 5 : 2012 GASTROINTESTINAL ENDOSCOPY 1100
At the Focal Point
nontender. Liver biochemical and pancreatic enzyme test results were normal. CT (A and B) demonstrated significant dilation (4 cm) of the entire main pancreatic duct (asterisk), with severe atrophy of the pancreatic parenchyma (small arrows). Neither pancreatic nor duodenal masses were documented, and no bile duct dilation was seen. ERCP revealed an enlarged major papilla orifice with spontaneous outflow of mucus (C). Pancreatography (D) confirmed significant dilation of the main pancreatic duct and showed it to be filled with mucus, which was removed by using an extraction balloon. Pancreatic ductal side branches were dilated mainly in the body and tail of the gland (arrows). No strictures were identified. The diagnosis of intraductal papillary mucinous neoplasm was proposed. A 7F, nasopancreatic drainage tube was placed for saline solution flushing of the duct, after which the abdominal mass did not substantially change in size, although the patient’s condition improved slightly after 3 days. The drain was removed, and the patient was discharged.
1101 GASTROINTESTINAL ENDOSCOPY Volume 75, No. 5 : 2012
Despite the fact that intraductal papillary mucinous neoplasm is a premalignant condition, surgery has not been scheduled for this patient because of her age and comorbid health conditions; clinical follow-up has been planned instead. DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Pietro Familiari, MD, PhD, Cristina Hervoso, MD, Ivo Boskoski, MD, Guido Costamagna, MD, Digestive Endoscopy Unit, Università Cattolica del Sacro Cuore, Gemelli University Hospital, Rome, Italy
doi:10.1016/j.gie.2012.01.018
www.giejournal.org
At the Focal Point
Commentary Intraductal papillary mucinous neoplasm (IPMN) first came to our attention in 1982 and now is an increasingly diagnosed entity that is well-recognized as a premalignant condition. Essentially, IPMN is a papillary neoplasm that arises from within the main pancreatic duct (there are variants that are confined to the side branches) and which produces large amounts of mucin that lead to chronic obstructive pancreatitis with ductal dilation. The involved ductal epithelium may demonstrate a range of histologic appearances from hyperplasia to dysplasia and carcinoma even within a single lesion. In recent series, malignant neoplasms account for a majority of IPMNs, most of which show invasive carcinoma at the time of diagnosis. As in this patient, most frequent symptoms of IPMN are abdominal pain and weight loss, not infrequently superimposed on a history of recurrent pancreatitis. The diagnosis is established by imaging studies, which typically reveal the dilated mucin-filled duct; ERCP shows a patulous ampulla with free-flowing mucus issuing from its os. As for the sausage here, this is just an extreme example of the degree to which a duct can dilate. The English humorist A.P. Herbert said, “A highbrow is one who looks at a sausage and thinks of Picasso.” For me, one who thinks of a dilated pancreatic duct when detecting what feels like a sausage in the abdomen, ah, now that’s an old-fashioned clinician. Lawrence J. Brandt, MD Associate Editor for Focal Points
Inverted diverticulum or adenomatous lesion? Identification using confocal laser endomicroscopy
A 59-year-old woman was seen for surveillance colonoscopy. She had no history of abdominal pain or rectal bleeding. Physical examination and results of laboratory investigations were unremarkable. High-resolution ileocolonoscopy revealed extensive diverticulosis in the sigmoid colon. Additionally, an 8-mm flat polyp with a central indentation and Kudo pit pattern II was found in the sigmoid colon (A). The polypoid structure showed no change in its appearance after air insufflation or palpation with biopsy forceps. To characterize the lesion more intensively, 5 mL of 10% fluorescein were administered intravenously, and the probe-based confocal laser endomicroscopy system (Cellvizio; Mauna Kea Technologies, Paris, France) was inserted through the working channel of the endoscope and gently pushed against the polypoid structure. Fluoresceinguided endomicroscopy revealed tubular architecture and nondysplastic cells (B). The polyp was removed by snare polypectomy, and the in vivo diagnosis of tubular adenoma without
www.giejournal.org
high-grade intraepithelial neoplasia was confirmed on histopathological analysis (C). DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Helmut Neumann, MD, PhD, Department of Medicine I, University of Erlangen-Nuremberg, Erlangen, Germany, Michael Vieth, MD, PhD, Institute of Pathology, Klinikum Bayreuth, Bayreuth, Germany, Raja Atreya, MD, PhD, Thomas Bernatik, MD, PhD, Jonas Mudter, MD, PhD, Markus F. Neurath, MD, PhD, Department of Medicine I, University of ErlangenNuremberg, Erlangen, Germany doi:10.1016/j.gie.2011.12.033
Volume 75, No. 5 : 2012 GASTROINTESTINAL ENDOSCOPY 1102