Karim T. Osman, MD, Daniel B. Maselli, MD; Mayo Clinic, Rochester, MN
Introduction: Groove pancreatitis (GP) is a rare type of segmental pancreatitis affecting the anatomic region between the pancreatic head, the duodenum, and the common bile duct. Greater than 90% of the cases manifest in men with preceding chronic tobacco and alcohol abuse, with a median age of 47 years at presentation. Here we describe an atypical case of GP in a 71-year-old female who quit smoking 30 years prior. To our knowledge, this is the latest presentation (2.5 decades beyond the median age) of GP in a female in the literature.
Methods: A 71-year-old female with chronic alcohol abuse (4 wine glasses per day for 30 years) presented with abdominal pain, progressive non-bloody emesis up to 12 times daily, and unintentional weight loss of 15 lbs over the prior month.
Non-contrast abdominal CT showed marked distention of the stomach, with air-fluid levels, suggesting gastric outlet obstruction (GOO). The pancreas was unremarkable except for mild punctate calcifications in the head. A suspected submucosal hematoma was observed at the pylorus and descending duodenum. Upper endoscopy showed extensive food residue in the stomach and benign-appearing stenosis at the pylorus, which did not respond to dilation. Presuming the obstruction was due to spontaneous duodenal hematoma, the patient was managed conservatively with liquid diet and anti-emetics.
One month later, MRI showed an enlarging submucosal hematoma between the descending duodenum and pancreatic head, which exerted mass effect on both structures (Figure 1). Given the patient’s continued alcohol use and hematoma location, she was diagnosed with GP and managed with nasojejunal feeds. Alcohol cessation was recommended. Four months later, the patient maintained abstinence from alcohol with the help of a counseling program, tolerated a full diet, and regained weight. CT scan showed a resolving hematoma (Figure 2). Discussion: GP is a rare form of pancreatitis that classically affects middle-aged men with long-term alcohol abuse. However, it is still imperative to consider the disease in elderly women presenting with GOO. Alcohol and tobacco cessation are recommended. Given that duodenal hematoma may suggest underlying cancer, malignancy should be thoroughly evaluated prior to the diagnosis of GP.
Figure 1. Follow up abdominal MRI where (A) is an axial view revealing a liquefied submucosal hematoma involving the pylorus and extending to the second portion of the duodenum, with a predominantly cystic, loculated structure (orange arrow). The complex duodenal hematoma measured 9.3 x 3.9 cm in anteroposterior x mediolateral dimensions, spanned 8 cm in length, and exerted mass effect on the upstream duodenal lumen (green arrow). Figure 1B is a coronal view illustrating the impressive luminal compression the submucosal hematoma (blue arrow) exerted on the duodenum (red arrow). There is mild dilation of the pancreatic duct.
Figure 2. Abdominal CT, four months after conservative dietary measures and alcohol cessation, showing a resolving hematoma that improved to approximately 2 cm in diameter. No associated mass effect on adjacent structures is present.
Disclosures: Karim Osman indicated no relevant financial relationships. Daniel Maselli indicated no relevant financial relationships.