Bifid Pancreatic Tail: an Anatomical Case Series and their Classification

Anomalies and variants of development of the pancreas are relatively frequent. Bifid pancreatic tail is a rare anatomic variation with only a few cases reported in the literature. The present case series were encountered during dissection of 50 anatomical specimens of the pancreas, spleen, and duodenum. We observed four unusual cases (8%) of bifid pancreatic tail. One case was of a vertically oriented bifid pancreas tail (2%), in another case, the tails here horizontally oriented (2%) and in two cases the bifid tails were horizontally oriented but unequal (4%). The bifid tails had an arterial supply that penetrated the glands between the tails and two out of four were also supplied by the superior horizontal pancreatic artery of Popova. The ductal system usually bifurcated at the level of the tails, but a case of trifurcation was also encountered. The current cases should be taken into account in hepato-pancreato-biliary surgery to avoid misdiagnosis and to comprehensively assess the patient preoperatively.

Pancreatic duct stones and laser treatment: A case report

A 62 years-old Caucasian male, who had a consumptive condition associated with recurrent episodes of abdominal pain, was evaluated in a Gastroenterology consultation. Physical examination was quite innocent and the following imaging exams were performed. A Computed Tomography (CT) showed a thin gallbladder and chronic pancreatitis signs with pancreatic intraductal stones, dominant at tail and body, associated with pancreatic tail atrophy. An abdominal-Magnetic Resonance Imaging (MRI) showed an abnormal pancreatic parenchyma, a mild Wirsung dilatation and an unknown pancreatic head stenosis etiology. Therefore, to clarify the pancreatic stenosis, an echo-endoscopy (EUS) was performed. This exam showed a 10-mmstone associated with a focal narrowing in the head/tail transition. A pancreatoscopy-guided holmium laser using a mini-endoscope inserted into the pancreatic duct successfully broke the impacted stone and cleared the obstruction, without complications. After that, endotherapy with plastic stents was repeatedly done, during the following 6 months. After endoscopic treatment, the patient recovered quite well, without any symptoms, without pancreatic stenosis and higher quality of life.

A Case of İntrapancreatic Accessory Spleen Mimicking a Pancreatic Metastasis on the 18F-FDG PET/CT Scan: A Case with Breast Cancer

The accessory spleen is a focus of splenic tissue which is separated from the main of the spleen. Although accessory spleens are generally recognized on computed tomography (CT), intrapancreatic accessory spleen (IPAS) may be mistaken for other pancreatic tail lesions. We report a case of IPAS mimicking a pancreatic metastasis on the 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT). A 41-year-old with diagnosed breast cancer (invasive ductal carcinoma) woman patient underwent an 18F-FDG PET/CT for metastasis screening and staging. 18F-FDG PET/CT showed a focal uptake in the pancreatic tail. The patient underwent a contrast-enhanced CT and magnetic resonance imaging (MRI) for lesion characterization. The density and intensity of lesion were similar to spleen on all phases and all sequences. The lesion was evaluated as IPAS. The diagnosis was confirmed by endoscopic ultrasound (EUS) biopsy. A case of IPAS positive at 18F-FDG PET/CT could not found in the literature. We present a case of IPAS mimicking a pancreatic metastasis positive at 18F-FDG PET/CT.

Carcinoma of Tail of Pancreas: A Case Report

Background: A typical manifestation of pancreatic tail cancer is large intestinal obstruction with perforation. Clinically the cancer of pancreas is usually complicated to diagnose. Most cancer patients are not having symptoms throughout during the initial stages of the cancer, which often leads to a delay in diagnosis. Treatment choices include surgery, chemotherapy, and palliative care. It is more common in African-Americans, slightly more common in men. Case Presentation: A female patient of 40 years from Wardha was admitted to Female surgery Ward, Unit-3, AVBRH on 18th December with a chief complaint of pain in epigastric region since 2weeks. Patient was apparently all right 2 months back then she was complaining of pain in the epigastric region which was insidious in onset, gradually progressive in nature, burning type of pain with radiating to left upper back. No history of fever, nausea vomiting, clay-coloured stools. After that patient was undergone on routine investigation in that total WBC count was increased i.e., 13000/cu mm and haemoglobin level were decreased i.e., 9.7gm%, liver biopsy revealed that metastasis of Adenocarcinoma probably of pancreatic origin, Computed tomography and ultrasound and it revealed that heterogenous iso-echoic mass in the tail of pancreas based on investigation she was diagnosed as a case of Carcinoma tail of pancreas and she was undergone on treatment of antibiotic before chemotherapy .after that chemotherapy treatment was done for management of pain. Conclusion: Pancreatic adenocarcinoma presents differently from large intestinal cancer and should be explored in the differential diagnosis of large intestinal obstruction.

Challenge of coexisting type 2 diabetes mellitus and insulinoma: a case report

Background Insulinomas are rare clinical entities, but concurrent diabetes mellitus is even more uncommon, and the combination is easily missed. Recurrent hypoglycemia could be misconstrued as improved glycemic control. We present an unusual patient with type 2 diabetes and neuroglycopenia, with apparent improved glycemic control due to an insulinoma. Case presentation A 54-year-old mixed ancestry man with a positive family history of type 2 diabetes mellitus was diagnosed with type 2 diabetes mellitus and hypertension 8 years prior to admission. He presented with episodes of abnormal behavior and hypoglycemia. Inappropriately high insulin and C-peptide concentrations were identified at the time of hypoglycemia. Despite poor adherence to his diabetic treatment, he had no target organ damage relating to diabetes, and his hemoglobin A1c (HbA1c) was 5.3%. A diagnosis of insulinoma was made, and he was started on diazoxide, with endoscopic ultrasound revealing a possible lesion in the pancreatic tail measuring 12 mm × 12 mm. A fine-needle aspiration biopsy could not be performed due to overlying splenic arteries and the risk of vascular perforation. An intraoperative ultrasound confirmed a 15 mm × 10 mm tumor in the pancreatic tail, necessitating a partial pancreatectomy and splenectomy, which were curative. A well-differentiated intermediate grade 2 pancreatic neuroendocrine tumor producing insulin was confirmed on histopathology. Conclusions Recurrent, progressive hypoglycemia and improved glycemic control in a diabetic, without an alternative explanation, may suggest an insulinoma. Insulinomas that exist with type 1 diabetes mellitus, particularly malignant insulinomas, must have escaped autoimmune attack through lack of autoantigen expression. Computed tomography on its own may be insufficiently sensitive for diagnosis of insulinomas, whereas endoscopic and intraoperative ultrasonography may improve the identification of the culprit lesion.