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 Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 2  |  Issue : 1  |  Page : 57-60

Groove pancreatitis presenting as recurrent acute pancreatitis


1 Department of Medical Gastroenterology, School of Digestive and Liver Disease (SDLD), Institute of Post-Graduate Medical Education and Research (IPGMER), Kolkata, West Bengal, India
2 Department of Surgical Gastroenterology, School of Digestive and Liver Disease (SDLD), Institute of Post-Graduate Medical Education and Research (IPGMER), Kolkata, West Bengal, India
3 Division of Gastrointestinal Pathology, School of Digestive and Liver Disease (SDLD), Institute of Post-Graduate Medical Education and Research (IPGMER), Kolkata, West Bengal, India
4 Division of Gastrointestinal Radiology, School of Digestive and Liver Disease (SDLD), Institute of Post-Graduate Medical Education and Research (IPGMER), Kolkata, West Bengal, India

Date of Web Publication4-Jun-2014

Correspondence Address:
Vishal Khurana
RN-111, Junior PG Doctor Hostel, 242 AJC Bose Road, Kolkata - 700 020, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2321-4848.133815

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  Abstract 

A middle aged male presented with recurrent acute pancreatitis without any feature of extrahepatic biliary obstruction. Evaluation revealed mass in groove area with duodenal lumen compromise without any features of chronic pancreatitis. He underwent classical Whipple's operation with the suspicion of periampullary tumor but histopathology was suggestive of groove pancreatitis ruling out malignancy. This case is first case to report recurrent acute pancreatitis as presentation of groove pancreatitis.

Keywords: Groove pancreatitis, recurrent acute pancreatitis, Whipple′s operation


How to cite this article:
Khurana V, Bandyopadhyay D, Ray S, Basu K, Bhattacharyya A. Groove pancreatitis presenting as recurrent acute pancreatitis. Arch Med Health Sci 2014;2:57-60

How to cite this URL:
Khurana V, Bandyopadhyay D, Ray S, Basu K, Bhattacharyya A. Groove pancreatitis presenting as recurrent acute pancreatitis. Arch Med Health Sci [serial online] 2014 [cited 2019 Dec 11];2:57-60. Available from: http://www.amhsjournal.org/text.asp?2014/2/1/57/133815


  Introduction Top


Groove pancreatitis is uncommon type of segment chronic pancreatitis's affecting pancreaticoduodenal groove area, often misdiagnosed as periampullary tumor resulting definite diagnosing after histopathological examination post-pancreaticoduodenectomy. [1],[2] We present one case of groove pancreatitis presenting as recurrent acute pancreatitis.


  Case Report Top


On 14 th January 2011, a 47-years-old non-diabetic-chronic alcoholic (60 mg/day for 10 years)-non-smoker Asian male brought to our emergency OPD with acute onset severe upper-abdominal deep agonizing pain radiating to the back associated with intermittent non-bilious-projectile vomiting for 3 days. He has history of 5 times hospitalization in various hospitals in last 1 year with these symptoms, each time diagnosed as acute pancreatitis and used to recover with conservative management, last admission 2 months back. He also had history of weight loss. He denied history of jaundice, abdominal distension, and overt gastrointestinal blood loss. His family or drug history was unremarkable. On examination, he was having cachectic look, tachycardia, and tender epigastrium. Rest of the systemic examination was normal. Working diagnosis of recurrent acute pancreatitis (RAP) was made.

At admission, his complete hemogram, renal and liver (LFT) function tests were within normal limits except for elevated ESR (32 mm/1 st hour; normal range 0-15 mm/h) and low albumin (3.2 mg/dl; normal range 3.5-5.5 g/dL). Serum amylase was 201 U/L (normal range 0-60 U/L) and lipase 584 U/L (normal range 0-190 U/L). His CA 19-9 and carcinoembryonic antigen (CEA) levels were within normal limit. Trans-abdominal ultrasound (US) revealed diffuse thickening of second part of duodenum with narrowing of duodenal lumen and bulky head of pancreas. Post-contrast axial computer tomograph (CT) scan of abdomen showed mild heterogenous enhancement of pancreatic head, circumferential mural thickening of second part of duodenum, and mild fluid collection in pancreaticoduodenal groove without any evidence of pancreatic atrophy, calcification, or ductal dilatation i.e. no evidence of chronic pancreatitis. Also, there was no evidence of ascitis, vascular involvement, or hepatobiliary system abnormality [Figure 1]. Upper GI endoscopy revealed narrowed second part of duodenum due to irregular polypoidal growth arising at D1-D2 junction with intact overlying mucosa [Figure 2]a-c. Radial endoscopic US (EUS) showed a mass present between pancreatic head and duodenum with normal pancreatic duct [Figure 3].
Figure 1: Post-contrast axial computer tomograph (CT) scan of abdomen

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Figure 2: Upper GI endoscopy showing duodenum (2nd part)

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Figure 3: Radial endoscopic ultrasound (EUS)

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Working etiological diagnosis of periampullary tumor versus groove pancreatitis was kept. He underwent Whipple`s (classical pancreaticoduodenectomy) operation with the suspicion of periampullary malignancy. Macroscopic examination of operated specimen revealed thickening of duodenal wall, fibrosis of pancreaticoduodenal groove, and few cystic spaces in the duodenal head [Figure 4]. Histological examination of tissue from the peripheral part of the head of pancreas showed marked degree of acinar atrophy, peri-acinar whirling pattern of fibrosis, multiple dilated ducts with intraluminal secretions, and few normal pancreatic Islets with intervening stroma shows widening, thick bands of fibroconnective tissue and scanty mononuclear inflammatory cell infiltration [Figure 5]a. Sections from the central part of the head of pancreas show histological features of pancreatic parenchyma within normal limits [Figure 5]b. Sections from the adjacent duodenal wall show few dilated and congested blood vessels in submucosa [Figure 5]c. Sections from pancreaticoduodenal groove show the presence of thick bands of fibroconnective tissue infiltrated with chronic inflammatory cells and merging with duodenal serosal fibrosis and peripancreatic fibrosis on both sides. No evidence of any granuloma or atypia seen in any of the sections. So, the histopathological diagnosis was given as Groove pancreatitis and was corroborative with the clinical and radiological diagnosis. Postoperative recovery was uneventful. Postoperatively, he never had abdominal pain and gained 17 kg weight in last 2 years. His body weight and body mass index before surgery were 45 kg and 16.53 kg/m2, respectively, and 2 years after surgery were 62 kg and 22.77 kg/m2, respectively. He was last followed up on 24/1/13 when his CT abdomen didn't showed any features of chronic pancreatitis (CP).
Figure 4: Macroscopic examination of operated specimen showing cut section showing duodenum, pancreas, and thickened pancreaticoduodenal groove area (groove area marked with small white boxes)

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Figure 5: Histopathological examination of operated specimen (H and E stain)

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  Discussion Top


Groove (paraduodenal) pancreatitis (GP) is uncommon form of chronic pancreatitis affecting groove area formed by duodenum, common bile duct, and pancreatic head, often masquerading as periampullary tumor, presenting in middle-aged alcoholic male with chronic pancreatitis. [1],[2] Patients usually have repeated attacks of recurrent acute pancreatitis culminating finally into chronic pancreatitis. Patients usually present with week to years history of recurrent pancreatic type pain, recurrent vomiting (due to duodenal stenosis, proportionate weight loss (due to less intake because of nausea and vomiting) or jaundice (due to biliary obstruction). Proposed mechanism is obstruction of pancreatic juice flow through Santorini`s duct at minor papilla caused by anatomical or functional obstruction (alcohol/smoking increases pancreatic juice viscosity) leading to inflammation of dorsal pancreas, increased pressure upstream eventually involve Wirsungian knee resulting in blockage of secretion from peripheral pancreatic ducts [Figure 6]. [3] Precipitation of proteinaceous plug in ducts leads to ductal calculi. [4] Pathologically, there is myofibroblast proliferation resulting in fibrosis and scarring of groove area (pure form of GP) or pancreatic head (segmental GP). Duodenal involvement in almost universal in the form of duodenal stenosis, Brunner's gland hyperplasia, or cystic change in duodenal wall. Investigation usually reveals elevated pancreatic enzymes (during attack of pancreatitis), normal tumor markers (CA 19-9 and CEA), deranged LFT if biliary obstruction and mass lesion in groove area on imaging. Main differential diagnosis is periampullary malignancy, which is difficult to differentiate based on blood investigation or imaging; only histology can resolve this issue with utmost certainty. [5],[6] Management is mainly conservative; role of minor papilla stenting/sphincterectomy is unknown, and pancreaticoduodenectomy is usually done with suspicion of periampullary malignancy or intractable pain. [7]

Our patient presented with features of RAP who subsequently underwent Whipple's operation for suspicion of periampullary malignancy and is healthy after 2 years of postoperative follow-up without any development of features of exocrine/endocrine insufficiency or any feature of CP on imaging. We propose that RAP should be included in definition of GP.
Figure 6: Pathogenesis of Groove pancreatitis. a- depicts the relationship of various structure in anatomically predisposed person without groove pancreatitis and b- depicts features in groove pancreatitis. Pancreatic parenchyma in groove area is drained by small ducts into Santorini's duct or directly into Wirsung's duct (if Santorini`s duct is rudimentary or absent, or if there is imperforated minor papilla). Precipitating factors, e.g. alcohol/smoking, which increases the viscosity of pancreatic juice, leads to stagnation of pancreatic juice flow resulting in occlusion of small ducts leading to pancreatitis. Repeated episodes of acute pancreatitis leads to myo-adenomatoid changes with expansion of groove area, which further increase the acute angle of Wirsungian knee, which further add-up to the obstructive component to pancreatic juice flow from peripheral pancreatic ducts (a-duodenum, b-bile duct, c-pancreas, d-Santorini's duct, e-Wirsung's duct, f-Wirsungian knee, g-expansion of groove area, h-increase in acute angle of Wirsungian knee)

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  References Top

1.Stolte M, Weiss W, Volkholz H, Rösch W. A special form of segmental pancreatitis: "groove pancreatitis. Hepatogastroenterology 1982;29:198-208.  Back to cited text no. 1
    
2.Becker V. Bauchspeicheldruse (Inselapperat ausgenommen). In: Doerr W, editor. Spezielle pathologische Anatomie. Berlin, Germany: Springer; 1973.  Back to cited text no. 2
    
3.Tezuka K, Makino T, Hirai I, Kimura W. Groove pancreatitis. Dig Surg 2010;27:149-52.  Back to cited text no. 3
    
4.Shudo R, Obara T, Tanno S, Fujii T, Nishino N, Sagawa M, et al. Segmental groove pancreatitis accompanied by protein plugs in Santorini's duct. J Gastroenterol 1998;33:289-94.  Back to cited text no. 4
    
5.Yamaguchi K, Tanaka M. Groove pancreatitis masquerading as pancreatic carcinoma. Am J Surg 1992;163:312-6.  Back to cited text no. 5
    
6.Mohl W, Hero-Gross R, Feifel G, Kramann B, Püschel W, Menges M, et al. Groove pancreatitis: An important differential diagnosis to malignant stenosis of the duodenum. Dig Dis Sci 2001;46:1034-8.  Back to cited text no. 6
    
7.Levenick JM, Gordon SR, Sutton JE, Suriawinata A, Gardner TB. A comprehensive, case-based review of groove pancreatitis. Pancreas 2009;38:e169-75.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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