Study of role of computerized tomography (CT) in evaluation of groove pancreatitis

Background: Groove pancreatitis is a rare form of chronic pancreatitis affecting the groove between the pancreatic head, duodenum and common bile duct. The exact cause of the disease is not known, although there are strong associations with long term alcohol abuse, functional obstruction of duct of Santorini and brunner gland hyperplasia. The purpose of this study was to describe the imaging findings of groove pancreatitis (GP) on Contrast enhanced CT Abdomen. Material and Methods: Present study was retrospective study conducted, with help of medical records of 16 patients with a final diagnosis of Groove pancreatitis. CT, MRI and MRCP findings were analysed. Statistical analysis was done using descriptive statistics. Results: In present study, two types of groove pancreatitis (GP) as pure type (50%) and segmental type (50%) were noted. Other important findings were focal duodenal wall thickening (62.5%) and cysts in the duodenal wall itself or in groove between the pancreatic head and the duodenum (37.5%), CBD dilatation and distal smooth tapering (62.5%) including all the segmental types and 2 of the pure type leading to intra- and extra-hepatic biliary system dilatation. MRI and MRCP were available in 6 patients in our study. There was a CT similarity regarding the sheet of tissues within the pancreaticoduodenal groove. These were seen expressing T1 hypo-intense and T2 slightly hyperintense signal in 3 patients with depiction of mild enhancement in the delayed phases in three of them (50%). On the MDCT examinations hypodense sheet at the PD groove was seen in 12 patients with modest enhancement identified in delayed phase seen in 6 of the them. Duodenal wall thickening was seen in 10 patients while associated cysts within the duodenal wall or in PD groove were seen in 6 patients. Pancreatic head enlargement with diffuse enhancement was seen in 8 patients. Mild pancreatic duct dilatation was seen in 8 patients while dilatation of the CBD was seen in 10 patients with distal tapering and intra-hepatic biliary dilatation. Conclusion: Groove pancreatitis (GP) is a disease that should be considered in the list of differential diagnosis of masses implicating the pancreatic head and medial duodenal wall. Imaging findings that are suggestive of GP include chronic inflammatory changes with fibrosis in the PD groove with or without implication of the nearby head of the pancreas, duodenal medial mural thickening with luminal stenosis and cysts at the PD groove or within the duodenal wall.

SCORE SYSTEM FOR ERCP INDICATING IN EXTRAHEPATIC BILE DUCT OBSTRUCTION

Abstracts. Aim: to objectify indications for urgent/emergency ERCP in patients with extrahepatic biliary tract obstruction (EBTO) by using the score system Matherials and Methods. The score is used by summing the points: hyperthermia ≥ 37.3 ° C (1 point); one of three hematological points — leukocytosis ≥ 9×109/l or stab neutrophils ≥ 7% or the ratio of the number of segmented and stab neutrophils <10 (1 point); two biochemical — serum bilirubin ≥ 70 μmol / l (1 point), hyperamylasemia (1 point); thickening of the gallbladder wall ≥ 4 mm or shrunken gallbladder (1 point); the main pancreatic duct dilatation (1 point); in the presence of a periampular tumor or signs of chronic pancreatitis, one point is subtracted (- 1 point). The scale was tested on 171 patients with EBTO. Results. The threshold value of the scale was ≥3 points (p <0.001). The number of points (3, ≥4) correlated with the severity of acute cholangitis and acute biliary pancreatitis (p <0.01). Conclusions. In patients with confirmed OEDB in case of ≤2 points of the score system — urgent/emergency ERCP is not indicated; in case of ≥3 points — urgent ERCP is indicated; in case of ≥4 points emergency ERCP should be performed.

The CT fish mouth ampulla sign: a highly specific finding in main duct and mixed intraductal papillary mucinous neoplasms

Objective: Main duct and mixed intraductal papillary mucinous neoplasms (IPMN) are pre-malignant cystic pancreatic neoplasms associated with pancreatic duct dilatation. Distinguishing these from benign causes of pancreatic duct dilatation is important in order to allow appropriate surveillance or surgery. A patulous duodenal papilla with extrusion of mucus at endoscopic evaluation, the endoscopic fish mouth ampulla (E-FMA) sign, is reported in main duct and mixed IPMN. We aimed to establish whether a CT correlate (CT-FMA) of this sign exists and whether this was associated with the presence of invasion or high-grade dysplasia. We defined the CT-FMA sign as an uninterrupted column of water attenuation material running from the pancreatic duct to the duodenal lumen. Methods: A retrospective, blinded review of 44 patients with histologically confirmed IPMN and 87 age-matched controls with pancreatic duct dilatation on CT was undertaken. A case–control series matched for the degree of pancreatic duct dilatation was used to compare the rates of invasion or high-grade dysplasia between main duct and mixed IPMN patients, with and without a CT-FMA sign. Results: The CT-FMA sign could be identified in 18.5% patients with main duct/mixed IPMN with specificity 100%, positive predictive value 100% and negative predictive value 79.8%. A significant association was found between CT-FMA in main duct/mixed IPMN compared to controls, but not with the presence of high-grade dysplasia or invasion. Conclusions: The CT-FMA sign is a newly reported, highly specific sign of MD and mixed IPMN. Advances in knowledge: If a fish mouth ampulla is identified at CT, a diagnosis of main duct or mixed IPMN is highly likely.