1694
the red section
nature publishing group
Images of the Month Am J Gastroenterol 2013;108:1694; doi:10.1038/ajg.2013.367
A rare extrapancreatic manifestation of acute pancreatitis. A 23-year-old woman with a history of heavy alcohol abuse presented with sharp epigastric pain and diffuse abdominal tenderness. Her lipase level was 5,428 U/L, and contrast-enhanced computed tomography (left) showed acute necrotic collection of the pancreas. She developed bilateral blurring of vision after 15 days. Fundoscopic examination revealed a pale optic nerve, hemorrhage at the fovea with whitish macular edema, and fine exudates localized nasal to the optic nerve (center). Fluorescent angiography showed severe delaying in both choroidal and retinal filling and a perifoveal hyperfluorescent material seen inferior to the fovea consistent with exudates (right). These findings were consistent with Purtscher’s-like retinopathy in the setting of acute alcoholic pancreatitis. (Submitted by Guru Trikudanathan, Mustafa Arain, Rajeev Attam, and Martin L. Freeman, Division of Gastroenterology, University of Minnesota, Minneapolis, Minnesota.)
A rare presentation of a pancreatic neuroendocrine tumor. A 53-year-old man was transferred from an outside hospital to our institution with the acute onset of hematemesis and melena over the preceding 48 hours. His history was significant for worsening fatigue and a 30-pound weight loss over the past year. The patient denied any history of liver disease or alcohol consumption. Laboratory examination showed a hemoglobin level of 5.1 g/dl (normal, 12–15 g/dl). Urgent index esophagogastroduodenoscopy (EGD) showed a large amount of blood in the fundus without a source of active bleeding (top left). Repeat EGD within 12 hours revealed isolated gastric varices in the fundus, with stigmata of recent bleeding (top right, arrows). Abdominopelvic computed tomography revealed a large, irregular, multilobulated low-density mass with surrounding peripheral enhancement in the pancreas, splenic vein thrombosis, and multiple gastric varices (bottom left). The patient underwent total pancreatectomy and splenectomy. Gross examination revealed a firm white and yellow-tan mass involving the entire length of the pancreas, which measured 12.0 × 6.0 × 5.2 cm. Histologic evaluation showed strongly immunoreactive chromogranin in the tumor cells, consistent with neuroendocrine differentiation (bottom right). (Submitted by Dennis Yang, Kevin E. Behrns, and Christopher E. Forsmark, University of Florida, Gainesville, Florida.) The American Journal of Gastroenterology
Volume 108 | NOVEMber 2013 www.amjgastro.com
the red section
nature publishing group
Images of the Month Am J Gastroenterol 2013;108:1694; doi:10.1038/ajg.2013.367
A rare extrapancreatic manifestation of acute pancreatitis. A 23-year-old woman with a history of heavy alcohol abuse presented with sharp epigastric pain and diffuse abdominal tenderness. Her lipase level was 5,428 U/L, and contrast-enhanced computed tomography (left) showed acute necrotic collection of the pancreas. She developed bilateral blurring of vision after 15 days. Fundoscopic examination revealed a pale optic nerve, hemorrhage at the fovea with whitish macular edema, and fine exudates localized nasal to the optic nerve (center). Fluorescent angiography showed severe delaying in both choroidal and retinal filling and a perifoveal hyperfluorescent material seen inferior to the fovea consistent with exudates (right). These findings were consistent with Purtscher’s-like retinopathy in the setting of acute alcoholic pancreatitis. (Submitted by Guru Trikudanathan, Mustafa Arain, Rajeev Attam, and Martin L. Freeman, Division of Gastroenterology, University of Minnesota, Minneapolis, Minnesota.)
A rare presentation of a pancreatic neuroendocrine tumor. A 53-year-old man was transferred from an outside hospital to our institution with the acute onset of hematemesis and melena over the preceding 48 hours. His history was significant for worsening fatigue and a 30-pound weight loss over the past year. The patient denied any history of liver disease or alcohol consumption. Laboratory examination showed a hemoglobin level of 5.1 g/dl (normal, 12–15 g/dl). Urgent index esophagogastroduodenoscopy (EGD) showed a large amount of blood in the fundus without a source of active bleeding (top left). Repeat EGD within 12 hours revealed isolated gastric varices in the fundus, with stigmata of recent bleeding (top right, arrows). Abdominopelvic computed tomography revealed a large, irregular, multilobulated low-density mass with surrounding peripheral enhancement in the pancreas, splenic vein thrombosis, and multiple gastric varices (bottom left). The patient underwent total pancreatectomy and splenectomy. Gross examination revealed a firm white and yellow-tan mass involving the entire length of the pancreas, which measured 12.0 × 6.0 × 5.2 cm. Histologic evaluation showed strongly immunoreactive chromogranin in the tumor cells, consistent with neuroendocrine differentiation (bottom right). (Submitted by Dennis Yang, Kevin E. Behrns, and Christopher E. Forsmark, University of Florida, Gainesville, Florida.) The American Journal of Gastroenterology
Volume 108 | NOVEMber 2013 www.amjgastro.com
