Resident Physician Aurora Health Care Oak Lawn, IL
Matthew Kobeszko, MD, MBA, MS1, Juan Gomez, MD2, Tarek Almouradi, MD2; 1Aurora Health Care, Oak Lawn, IL; 2University of Illinois at Chicago, Advocate Christ Medical Center, Oak Lawn, IL
Introduction: Pancreatic cancer accounts for about 3% of all cancers in the US and carries a high mortality index with less than 7% chance of survival 5 years after diagnosis. We present a rare case of an elderly female with pancreatic head cancer who presented as a pancreatic abscess with pancreatolithiasis.
Methods: An 82 year old female with past medical history of diabetes presented with complaints of generalized weakness and left upper quadrant pain of 1 week duration. Diffuse pain was elicited on abdominal exam. Initial laboratory work-up was remarkable for lipase 1024 unit/L, WBC 21.5, Hb 11.0 gm/dL, lactic acid 2.3 mmol/L, and creatinine 1.57 mg/dL. An abdominal CT was performed that demonstrated an extensive inflammatory process in the left upper quadrant with fluid collection consistent with an abscess and possible choledocolithiasis at the pancreatic head. The common bile duct measured 8 mm in diameter. The patient was fluid resuscitated and started on antibiotics with Zosyn and Flagyl. Interventional radiology was consulted and a percutaneous abscess drain was placed. An X-ray colonography with water soluble contrast demonstrated no evidence of colonic extravasation. MRCP revealed a 1.2 cm pancreatic ductal stone at the level of head with severe upstream distention of the pancreatic duct and an ill-defined hypoenhancing region (Figure 1). She was taken for endoscopic ultrasound that confirmed a dilated pancreatic duct with a shadowing hyperechoic stone and hypoechoic changes measuring about 3.5 cm in the head/neck area (Figure 2 & 3). An FNA biopsy confirmed adenocarcinoma of the pancreatic head. The patient was started on neoadjuvant chemotherapy and was referred to surgery for further management. Discussion: Despite a known complication from pancreatitis, pancreatic abscesses are rarely seen in conjunction with pancreatic cancer with literature limited to case reports. Our case additionally has a confounding factor of lithiasis in the main pancreatic duct, which can frequently be the cause of acute pancreatitis. Pancreatolithiasis is not commonly identified by clinical means, but its presence should always encourage clinicians to investigate further. In a series of case reports published by Zhang discovered that pancreatic cancer was the underlying cause of pancreatolithiasis in 19% of patients. Therefore, the importance of guideline directed workup is highlighted in this patient, as early detection of pancreatic cancer is commonly difficult, but can be potentially life-saving.
Figure 1. MRCP demonstrating pancreatolithiasis
Figure 2. Endoscopic ultrasound demonstrating hypoechoic mass
Figure 3. Endoscopic ultrasound demonstrating shadowing hyperechoic stone
Disclosures: Matthew Kobeszko indicated no relevant financial relationships. Juan Gomez indicated no relevant financial relationships. Tarek Almouradi indicated no relevant financial relationships.