ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Grace Elta and Robert J. Fontana, Section Editors
An Unusual Case of a Pancreatic Cyst Kurt Michael Reichermeier, Martin Caselitz, and Siegfried Wagner Donauisar Klinikum Deggendorf, Medizinische Klinik II, Deggendorf, Germany
Question: A 54-year-old woman presented with a diverticulitis of the sigmoid colon. Computed tomography demonstrated an incidental semiliquid, cystic mass at the head of the pancreas (Figure A, arrow). Subsequent endoscopic ultrasonography showed the lesion to be a 15-mm hypoechoic, but not anechoic, cyst containing a marginal, hyperechoic, circular nodule with a diameter of 5 mm (Figure B, arrow). The lesion did not seem to connect to the main pancreatic duct. The common hepatic duct and common bile duct were not enlarged and the major papilla seemed normal. Cyst fluid analysis revealed mainly periodic acid-Schiff–positive mucus and a few inflammatory cells as well as a few weakly proliferative ductal cells (Figure C). Levels of carcinoembryonic antigen could not be determined owing to the viscous composition of the cyst fluid. There was no prior history of upper abdominal pain, pancreatitis, weight loss or diarrhea. What is the diagnosis? What is the appropriate management? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Conflicts of interest The authors disclose no conflicts. © 2014 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2014.04.049
Gastroenterology 2014;147:e1–e2
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Answer to the Clinical Challenges and Images in GI Question: Image 1: Bronchiogenic Cyst
The results of endoscopic ultrasonography and cyst fluid analysis suggested a branch duct-type intraductal papillary mucinous neoplasia (IPMN). The case was presented at a multidisciplinary tumor board and according to the 2012 Tanaka criteria surgical resection was suggested and an uneventful pancreaticoduodenectomy was performed.1 Surprisingly, the macroscopic and microscopic evaluation of the resected specimen (Figure D; *, cyst; D, duodenum; P, pancreas; CBD, common bile duct; GB, gallbladder) showed a benign, bronchiogenic cyst at the head of the pancreas adjacent to the common bile duct. The cyst was lined with respiratory epithelium lacking any atypical features and contained smooth muscle tissue (Figure E; RE, respiratory epithelium; SM, smooth muscle) as well as lobes of seromucinous glands within the surrounding connective tissue (Figure F; SMG, seromucinous glands). Bronchiogenic cysts represent congenital anomalies, which evolve during the development of the tracheobronchial tree from the ventral foregut and are usually located above the diaphragm. In very rare cases, these cysts migrate caudally before fusion of the diaphragm and can therefore be located in the retroperitoneal space. Bronchiogenic cysts within the pancreatic gland have been reported
An Unusual Case of a Pancreatic Cyst Kurt Michael Reichermeier, Martin Caselitz, and Siegfried Wagner Donauisar Klinikum Deggendorf, Medizinische Klinik II, Deggendorf, Germany
Question: A 54-year-old woman presented with a diverticulitis of the sigmoid colon. Computed tomography demonstrated an incidental semiliquid, cystic mass at the head of the pancreas (Figure A, arrow). Subsequent endoscopic ultrasonography showed the lesion to be a 15-mm hypoechoic, but not anechoic, cyst containing a marginal, hyperechoic, circular nodule with a diameter of 5 mm (Figure B, arrow). The lesion did not seem to connect to the main pancreatic duct. The common hepatic duct and common bile duct were not enlarged and the major papilla seemed normal. Cyst fluid analysis revealed mainly periodic acid-Schiff–positive mucus and a few inflammatory cells as well as a few weakly proliferative ductal cells (Figure C). Levels of carcinoembryonic antigen could not be determined owing to the viscous composition of the cyst fluid. There was no prior history of upper abdominal pain, pancreatitis, weight loss or diarrhea. What is the diagnosis? What is the appropriate management? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Conflicts of interest The authors disclose no conflicts. © 2014 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2014.04.049
Gastroenterology 2014;147:e1–e2
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Answer to the Clinical Challenges and Images in GI Question: Image 1: Bronchiogenic Cyst
The results of endoscopic ultrasonography and cyst fluid analysis suggested a branch duct-type intraductal papillary mucinous neoplasia (IPMN). The case was presented at a multidisciplinary tumor board and according to the 2012 Tanaka criteria surgical resection was suggested and an uneventful pancreaticoduodenectomy was performed.1 Surprisingly, the macroscopic and microscopic evaluation of the resected specimen (Figure D; *, cyst; D, duodenum; P, pancreas; CBD, common bile duct; GB, gallbladder) showed a benign, bronchiogenic cyst at the head of the pancreas adjacent to the common bile duct. The cyst was lined with respiratory epithelium lacking any atypical features and contained smooth muscle tissue (Figure E; RE, respiratory epithelium; SM, smooth muscle) as well as lobes of seromucinous glands within the surrounding connective tissue (Figure F; SMG, seromucinous glands). Bronchiogenic cysts represent congenital anomalies, which evolve during the development of the tracheobronchial tree from the ventral foregut and are usually located above the diaphragm. In very rare cases, these cysts migrate caudally before fusion of the diaphragm and can therefore be located in the retroperitoneal space. Bronchiogenic cysts within the pancreatic gland have been reported
