Epidermoid cyst in the intrapancreatic accessory spleen is extremely rare condition which could be mistaken for pancreatic cystic neoplasm. We report two cases of epidermoid cysts of intrapancreatic accessory spleen which mimicking pancreatic cystic neoplasm. Two patients, both male, aged 47 and 53 respectively were referred to our department for pancreatic mass. One was asymptomatic, whereas the other presented worsening abdominal pain and progressive weight loss. In both cases, the mass with cystic component was detected in the pancreatic tail in a computed tomography scan. Under a suspicion of pancreatic cystic neuronendocrine tumor, they underwent a distal pancreatectomy. Pathologic feature of resected specimens were shown to benign squamous lined cyst with splenic tissue in and around cyst wall which suggested that epidermoid cysts in the accessory spleen. We should take into account the possibility of epidermoid cyst in the intrapancreatic accessory spleen in the differential diagnosis of pancreatic cystic lesion.
Abdominal Pain ; Diagnosis, Differential ; Epidermal Cyst* ; Humans ; Male ; Pancreatectomy ; Pancreatic Cyst* ; Pancreatic Neoplasms ; Spleen* ; Weight Loss

Intraductal papillary mucinous neoplasm of the pancreas (IPMN) is characterized by the production of mucin and marked dilatation of pancreatic duct. There are only several cases reports about fistula formation with adjacent organs in IPMN. A 61-year-old man was admitted due to jaundice and weight loss. CT scans showed that multiloculated cystic mass had replaced the body and tail of the pancreas. Interestingly, a fistula was found between cystic mass and duodenal bulb. With a diagnosis of malignant IPMN and pancreatoduodenal fistula, endoscopic forcep-biopsy was performed at the orifice of the fistula and pancreatic duct, through the fistula, under a fluoroscopic guidance. Pathologic examination showed only inflammatory cells. Direct peroral pancreatoscopy was performed through the pancreatoduodenal fistula using a standard upper endoscope with saline irrigation. Endoscopic forcep-biopsy was performed on the papillary tumor. Pathologic examination revealed intestinal type IPMN and radical total pancreatectomy was performed. Pathologic examination of the surgical specimen showed tubular adenocarcinoma arising from 15 cm sized intestinal type IPMN.
Adenocarcinoma ; Diagnosis ; Dilatation ; Endoscopes* ; Endoscopy ; Fistula* ; Humans ; Jaundice ; Middle Aged ; Mucins* ; Pancreas* ; Pancreatectomy ; Pancreatic Ducts ; Tomography, X-Ray Computed ; Weight Loss

A 77-year-old woman was admitted with 5 days history of melena. She had an open cholecystectomy 30 years ago. Abdominal computed tomography and duodenoscopy revealed massive hemobilia. Angiography showed right hepatic arterial fistula to common bile duct near the surgical clip. Embolization was done successfully and the patient recovered. We experienced a case of a massive hemobilia which was occurred after a long period of time since open cholecystectomy without pseudoaneurysmal change of the right hepatic artery. And we suggest the direct vessel injury and fistula between the bile duct and a blood vessel as a possible cause of hemobilia in this case.
Aged ; Aneurysm, False ; Angiography ; Bile Ducts ; Blood Vessels ; Cholecystectomy* ; Common Bile Duct ; Duodenoscopy ; Female ; Fistula ; Hemobilia* ; Hepatic Artery ; Humans ; Melena ; Surgical Instruments

A bezoar is a mass formed by the accumulation of digested food. A biliary bezoar, namely a bezoar formed in the bile duct, is rare, which occurs mostly in patients who formerly underwent cholecystectomy. It appears that incompetent sphincter produces occasional reverse flow of foreign bodies including undigested food from the alimentary canal into the bile tract. Surgical treatment is used for huge biliary bezoar which is too huge to be removed by nonsurgical treatment. Extracorporeal shock wave lithotripsy (ESWL) is mostly used to fragment renal or urinary calculi, but may be sparingly used against biliary calculi. This is to report the rare case of a patient with biliary bezoar who formerly underwent open cholecystectomy and choledocoduodenostomy. The patient's huge biliary bezoar was removed by ESWL and the successive execution of endoscopic retrograde cholangio pancreatography (ERCP). ESWL is expected to be a comparatively safe and convenient solution to huge biliary bezoars.
Bezoars* ; Bile ; Bile Ducts ; Cholecystectomy ; Foreign Bodies ; Gallstones ; Humans ; Lithotripsy ; Shock ; Urinary Calculi

Biliary invasion by hepatocellular carcinoma (HCC) is much less common. Patients manifest obstructive jaundice as the initial complaint, but most of them are inoperable. We report a case of completely improved biliary invasion in HCC after transcatheter arterial chemoembolization (TACE). A 61-year-old woman was referred for evaluation of jaundice. A biliary invasion of huge HCC was confirmed by image of abdominal computerized tomography (CT) and biopsy specimen. After improvement of jaundice by endoscopic retrograde biliary drainage and percutaneous transhepatic biliary drainage, she underwent TACE as a palliative treatment. Follow-up CT showed partial lipiodol uptake in hepatic tumor and its bile duct invasion. In follow-up endoscopic retrograde cholangiopancreatography, occluded cholangiogram showed neither luminal obstruction nor filling defect after removal of biliary stent. Our case suggests that obstructive jaundice, caused by inoperable huge HCC with biliary invasion, may be expected to resolve successfully biliary obstruction by a choice of TACE.
Bile Ducts ; Biliary Tract ; Biopsy ; Carcinoma, Hepatocellular* ; Cholangiopancreatography, Endoscopic Retrograde ; Drainage* ; Ethiodized Oil ; Female ; Follow-Up Studies ; Humans ; Jaundice ; Jaundice, Obstructive* ; Middle Aged ; Palliative Care ; Phenobarbital ; Stents

Autoimmune pancreatitis or IgG4-related sclerosing cholangitis often involves the liver. Most common lesion involving the liver is shown as mass or masses often referred as inflammatory pseudotumor. Inflammatory pseudotumor usually needs to be discriminated with malignancy. Here we report a case of IgG4-related sclerosing cholangitis with liver involvement presented as a mass. It was proven by biopsy and did not show any evidence of autoimmune pancreatitis. The mass infiltrated around the portal tract and portal vein thrombosis was also present.
Biopsy ; Cholangitis, Sclerosing* ; Granuloma, Plasma Cell ; Liver* ; Pancreatitis ; Venous Thrombosis

BACKGROUND/AIMS: The incidence of duodenal tumors has increased by health surveillance. However, preoperative diagnosis of subepithelial duodenal tumors remains difficult because of the wide variety of pathologies and the location of the tumors. We analyzed endoscopic, radiological, and pathological features of subepithelial benign duodenal tumors (BDTs), which were treated by surgical resection. METHODS: Five patients with subepithelial BDTs treated by surgical resection were analyzed retrospectively. We compared the preoperative and postoperative diagnosis and evaluated the clinical presentations, endoscopic and radiological findings, surgical treatments, pathological results, and outcomes of these patients. RESULTS: All the patients underwent successful surgical resection. There were two cases of gastrointestinal stromal tumors (GISTs) treated with segmental duodenectomy, one case of carcinoid tumor treated with antrectomy, one case of gangliocytic paraganglioma treated with ampullectomy, and a lipoma removed by mass excision. The two GISTs were in the duodenal third and fourth segment close to the pancreas, and it was difficult to exclude pancreatic tumors by imaging studies. All the patients remained healthy for more than three years. CONCLUSIONS: Subepithelial BDTs are rare and difficult to diagnosis. Awareness and preoperative diagnosis of subepithelial BDTs can lead to minimally invasive treatment, including endoscopic or local surgical resection.
Carcinoid Tumor ; Diagnosis ; Duodenum ; Gastrointestinal Stromal Tumors ; Humans ; Incidence ; Lipoma ; Pancreas ; Paraganglioma ; Pathology ; Retrospective Studies

In the initial genetic studies about pancreatitis in Korea, gene mutations were thought to be rare. However, the recent findings of PRSS1, SPINK1, and CFTR mutations in patients with idiopathic chronic pancreatitis or inherited cases of chronic pancreatitis are much more common than originally predicted. Therefore, it is important to identify underlying genetic background in idiopathic chronic pancreatitis to avoid progression and development of complications. In addition, concentrated and strict follow-up must be given to the patients because of very high risk of pancreatic cancer. However, it is also true that studies about genetics in pancreatitis were not enough to compare with Western studies. Accordingly, further large scale studies are necessary to find other unknown possible genes that could be related to the chronic and hereditary pancreatitis.
Genetics* ; Humans ; Korea ; Pancreatic Neoplasms ; Pancreatitis* ; Pancreatitis, Chronic

Autoimmune pancreatitis should be differentiated from pancreatobiliary cancers because they often have similar clinical features and images. Accurate and practical diagnostic algorithm for AIP is important to avoid unnecessary surgery and delayed treatment. International Consensus Diagnostic Criteria for AIP suggested that diagnostic algorithms and the practical patterns considerably vary worldwide. Patients with clinically suspected AIP can be categorized into patients with typical features of AIP and patients with indeterminate features based on CT findings. Serology and other organ involvement can be used as collateral evidence of AIP. If a patient presents with diffuse pancreatic enlargement but is lack of collateral evidence, pancreatogram could be useful. If a patient has obstructive jaundice, biliary drainage and endobiliary biopsy are recommended. Duodenal papillary biopsy for IgG4 immunostain can be used during ERCP. In case of atypical imaging findings, EUS-guided FNA/biopsy is recommended to exclude pancreatic cancer and to obtain the suggestive findings of AIP. If type 2 is clinically suspected, EUS-guided core biopsy is required for the definite diagnosis. Short-term steroid trial can be performed to confirm the diagnosis of AIP when pancreatobiliary cancer workup shows negative results. However, clinical practice in diagnosing AIP varies depending on the local expertise, facilities, cost, prevalence of AIP and its subtypes.
Biopsy ; Cholangiopancreatography, Endoscopic Retrograde ; Consensus ; Diagnosis ; Drainage ; Humans ; Immunoglobulin G ; Jaundice, Obstructive ; Korea ; Pancreatic Neoplasms ; Pancreatitis* ; Prevalence ; Unnecessary Procedures

The diagnosis of autoimmune pancreatitis (AIP) is clinically challenging because it is a rare disease, which closely mimics more common pancreaticobiliary malignancies in its presentation such as obstructive jaundice and pancreatic mass. The price of misdiagnosis is high because AIP diagnosed as pancreatic cancer can lead to unnecessary surgery for the benign disease, and cancer diagnosed as AIP can delay potentially curative surgery. There is no single ideal diagnostic test for AIP; hence one has to use a set of diagnostic criteria to distinguish it from other diseases. International consensus diagnostic criteria (ICDC) and algorithm for AIP have been proposed by a consensus of expert opinion in 2011. The concept of the Japan pancreas society (JPS) 2011 criteria took basic concepts of both the Japanese previous criteria and type 1 in the ICDC as much as possible. However, the ICDC are very complex to remember and definition of level 1 and 2 are not evidence based in some criteria. The revised JPS criteria are simpler than ICDC but further evaluation is necessary in other than Japan. So, further research is required to establish easy, ideal and practical diagnostic criteria.
Asian Continental Ancestry Group ; Consensus ; Diagnosis ; Diagnostic Errors ; Diagnostic Tests, Routine ; Expert Testimony ; Humans ; Japan ; Jaundice, Obstructive ; Pancreas ; Pancreatic Neoplasms ; Pancreatitis* ; Rare Diseases ; Unnecessary Procedures