P1153 - A Case of Intraductal Papillary-Mucinous Neoplasm of the Pancreas Penetrating into the Stomach and Colon: A Rare Presentation

Khadija Naseem, MD¹, Abdullah Sohail, MD², Adil Memon, MD¹, Hamza Shah, DO^3
1West Virginia University, Charleston Division, Charleston, WV; ²West Virginia University Charleston Division, Charleston, WV; ³Charleston Gastroenterology, Charleston, WV

Introduction: Intraductal papillary mucinous neoplasms (IPMNs) are potentially malignant intraductal epithelial neoplasms composed of mucin-producing columnar cells which arise from the main pancreatic duct or branches. It is a slow-growing tumor, and most of the time, it is found as an incidental finding on cross-sectional imaging performed for other purposes. We report a newly diagnosed case of IPMN in an asymptomatic patient forming a fistula extending into the stomach and left colon on presentation.

Case Description/Methods: A 79-year-old female without significant past medical history was sent to the emergency department after found to have an abnormal finding in the computed tomography (CT) scan of her abdomen. She was having generalized weakness, fatigue, and 20 lb unintentional weight loss over the last few weeks, for which her primary care physician ordered a CT scan. Her abdominal examination was completely normal. She denied any nausea, vomiting, jaundice, constipation or diarrhea. She had normal laboratory findings except for an elevated CA-19 of 556. Her CT abdomen showed large intra and extrahepatic fluid collection measuring 6.1 x 4.2 cm in size extending from the pancreatic head to the stomach and left colon, containing air with dilatation of the pancreatic and bile ducts. She underwent esophagogastroduodenoscopy (EGD) with endoscopic ultrasound (EUS) for the evaluation of the pancreatic mass. During the EGD, she was found to have a large amount of thick and gelatin-like mucus, overlying a fistulous cavity in the proximal body of the stomach on the posterior wall near the lesser curvature. The EUS confirmed the CT scan findings, and a fine needle aspiration (FNA) was performed of the thick gelatinous fluid and was sent for the fluid studies, including carcinoembryonic antigen (CEA), amylase, cytology, and genomic markers. Her CEA level came back 90,140 ng/mL, amylase 1, 080 U/L with cytology confirming the diagnosis of IPMN. The patient was transferred to the higher care facility for complete surgical resection of the mass and the fistulous tract.

Discussion: Fistula formation is an infrequent and late complication of IPMN; however, in our case patient presented with fistulous disease secondary to IPMN, which is itself a very unique and rare presentation. Nevertheless, once diagnosed, these patients should get surgery to remove the tumor and fistula to avoid possible further malignant dissemination.


Figure: Figure: (A) Computed Tomography of the abdomen showing pancreatic mass, (B) EGD image showing the thick gelatinous material in the stomach, (C) and (D) Endoscopic ultrasound images showing disrupted main duct IPMN causing extensive fistula tracts to the stomach, bile duct, duodenum and colon.


Disclosures:
Khadija Naseem indicated no relevant financial relationships.
Abdullah Sohail indicated no relevant financial relationships.
Adil Memon indicated no relevant financial relationships.
Hamza Shah indicated no relevant financial relationships.


Khadija Naseem, MD¹, Abdullah Sohail, MD², Adil Memon, MD¹, Hamza Shah, DO³. P1153 - A Case of Intraductal Papillary-Mucinous Neoplasm of the Pancreas Penetrating into the Stomach and Colon: A Rare Presentation, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.