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Dynamic Contrast-Enhanced MRI Findings of Acute Pancreatitis in Ectopic Pancreatic Tissue: Case Report and Review of the Literature

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Dynamic Contrast-Enhanced MRI Findings of Acute Pancreatitis in Ectopic Pancreatic Tissue: Case Report and Review of the Literature University of Massachusetts Medical School eScholarship@UMMS Radiology Publications and Presentations Radiology 2014-07-28 Dynamic contrast-enhanced MRI findings of acute pancreatitis in ectopic pancreatic tissue: case report and review of the literature Senthur Thangasamy University of Massachusetts Medical School Et al. Let us know how access to this document benefits ou.y Follow this and additional works at: https://escholarship.umassmed.edu/radiology_pubs Part of the Digestive System Diseases Commons, and the Radiology Commons Repository Citation Thangasamy S, Zheng L, Mcintosh LJ, Lee P, Roychowdhury A. (2014). Dynamic contrast-enhanced MRI findings of acute pancreatitis in ectopic pancreatic tissue: case report and review of the literature. Radiology Publications and Presentations. https://doi.org/10.6092/1590-8577/2390. Retrieved from https://escholarship.umassmed.edu/radiology_pubs/259 Creative Commons License This work is licensed under a Creative Commons Attribution 4.0 License. This material is brought to you by eScholarship@UMMS. It has been accepted for inclusion in Radiology Publications and Presentations by an authorized administrator of eScholarship@UMMS. For more information, please contact [email protected]. JOP. J Pancreas (Online) 2014 July 28; 15(4):407-410 CASE REPORT Dynamic Contrast-Enhanced MRI Findings of Acute Pancreatitis in Ectopic Pancreatic Tissue: Case Report and Review of the Literature Senthur J Thangasamy1, Larry Zheng1, Lacey McIntosh1, Paul Lee2, Abhijit Roychowdhury1 1Department of Radiology and 2Pathology, University of Massachusetts Memorial Medical Center, Worcester, MA, USA ABSTRACT Context Acute pancreatitisCase report in ectopic pancreatic tissue is an uncommon cause of acute abdominal pain and can be difficult to diagnose on imaging. Our aim is to raise awareness and aid in the diagnosis of this entity by highlighting helpful dynamic contrast-enhanced MRI imaging findings. We report a 51-year-old man with acute onset epigastric pain presented to ER. With the presence of elevated serum lipase, the clinical diagnosis of acute pancreatitis was made. Contrast enhanced CT demonstrated normal pancreas and a focal mass at the duodenojejunal flexure, mimicked a neoplasm. Subsequent dynamic contrast enhanced MR images demonstrated enhancement provedpattern asof anthe ectopic lesion pancreaticsimilar to thetissue native on microscopic pancreatic tissueexamination. enhancement, Conclusion a finding raised the possibility of acute pancreatitis in ectopic MRpancreatic imaging tissue, can be but characteristic tumor was notand excluded. diagnostic Finally, of acute patient pancreatitis undergone in ectopic surgical pancreatic bowel resection tissue in including the appropriate the suspected clinical mass setting. that was We concluded that findings on dynamic contrast enhanced INTRODUCTION Acute pancreatitis is the most common gastro-intestinal diagnosedescribed this our condition. case, reviewed relevant literature, and causes of acute hospitalization in the United States [1]. discussed the radiologic findings which are helpful to Acute pancreatitis is a clinical diagnosis, usually made CASE REPORT A 51-year-old male presented in the emergency department biochemical markers such as elevated amylase and lipase [2].on history, physical exam findings and correlation with Even in the setting of elevated serum pancreatic enzymes hypercholesterolemia,with acute onset of epigastric hypertriglyceridemia, pain, radiating to and both coronary flanks. arteryPast medical disease historystatus post was stent significant placement. for hypertension,Social history appear normal in CT imaging in very early, non necrotizing pancreatitisand clinical findings i.e. Balthazar of acute grade pancreatitis, A acute the pancreatitis pancreas may [3]. The sensitivity of CT and MRI in detection of severe acute was significant for tobacco use and alcohol abuse. On pancreatitis is 78% and 91% respectively [4, 5]. In such U/Lphysical (reference examination, range: the 0-50 abdomen U/L), rise was in distended serum aspartate eliciting a situation, it is also important to consider the possibility transaminasemild diffuse tenderness. at 123 U/L Serum(reference lipase range: was elevated10-40 U/L) at 177and of acute pancreatitis in ectopic pancreatic tissue since rise in serum alanine transaminase at 196 U/L (reference the incidence ectopic pancreas is up to 14% at autopsy range: 10-40 U/L). The clinical diagnosis of acute diagnosis[6]. Awareness and differentiating of this entity itand from knowledge other mimickers of pertinent such pancreatitis was made and decided to perform CT study. asimaging submucosal findings tumors. will aid Thereby, in detecting an appropriate this uncommon initial MedicalIn the ER, Solution). CT examination Contrast-enhanced was performed CT in on venous a 256-slice phase dual source scanner (SOMATOM Definition Flash, Siemens conservative management can be performed without (80 sec delay) was done after intravenous administration misdirectionAt our institution, towards encountered surgery or a biopsy.case of acute pancreatitis slice-thicknessof 80 cc of Omnipaque of 5 mm 300 in (iohexol axial, coronal with iodine and contentsagittal planes.of 300 Themg/mL). images The demonstrated datasets were a focal reconstructed mass measuring with in ectopic pancreas located in the jejunum with imaging featuresReceived Aprilidentical 3rd, 2014 to –a Accepted submucosal June 13th, tumor. 2014 Here, we have separate from normal appearing pancreatic body (Figure Key words Choristoma; Magnetic Resonance Imaging; Pancreas; Pancreatitis, Acute Necrotizing 2.5 x 2.8 cm, located at the duodenojejunal flexure and Correspondence Senthur J Thangasamy thickening and adjacent mesenteric fat stranding. The Department of Radiology 1a-c). Additionally, there was focal, moderate jejunal wall University of Massachusetts Memorial Medical Center Worcester, Massachusetts tumor or jejunal diverticulitis. USA constellation of these findings suggested a submucosal Phone +1-508.334-1000 Fax: +1-774.442-3785 E-mail [email protected]; [email protected] With the given atypical findings, it was decided to perform MRI study with MRCP sequences. On the next day after JOP. Journal of the Pancreas - http://www.serena.unina.it/index.php/jop - Vol. 15CT, No. 4the – July MR 2014. examination [ISSN 1590-8577] was done on a 1.5T system407 JOP. J Pancreas (Online) 2014 July 28; 15(4):407-410 Figure 1. Contrast-enhanced CT in portal venous phase (a-c d ) shows a jejunal mass (block arrow) with density similar to the normal native pancreatic Jejunumdensity (arrowhead). is marked as Note. the adjacent edematous thick wall duodenum and proximal jejunum. ( ) MRCP demonstrates the relation between native pancreas (thin long arrow-main pancreatic duct) and ectopic pancreas near the duodenojejunal flexure. No accessory duct was demonstrated in this case. edema, and granularity of the mucosa at duodenojejunal (MR Signa EXCITE, GE Healthcare). MRCP sequence process. Nearly 2 months after the initial ER admission, axialradial andSSFE, coronal coronal FIESTA2DSSFE (5mm/0gap),with fat-sat andaxial 3D eDWI FSE; flexure along with finding suggestive of extra luminal (7mm/0gap),then, axialT2-weighted axial LAVA FSE Flex (7/8 in-phase mm; 80 andand out-phase160 TEs), jejunal mass. Gross examination of operative specimen (5mm/0gap) and dynamic contrast-enhanced axial LAVA the patient had undergone surgical wedge resection of the Flexin early arterial (triggered at right atrium), 30 sec, serosa and mucosa on either side. The cut surface of showed 3.0 x 2.2 x 1.0 cm soft tissue fragment between minutes after intravenous contrast injection (18 cc of muscularis propria and submucosa. 1 min and 3 min(5mm/0gap) followed by coronal in 5 the mass was lobulated tan/yellow tissue within the DISCUSSION Multihance; gadobenate dimeglumine 0.1 mmol/kg) were performed. All these sequences were done during breath- tissue outside the anatomic location of the pancreas revealedhold except a 2.5 axial x 2.8 T2-weighted cm focal mass and at3D the FSE duodenojejunal MRCP which Ectopic pancreatic tissue is defined as presence of pancreas were performed with respiratory trigger. These images without any anatomic continuity or vascular connection suggestingflexure which ectopic mimicked pancreatic the tissuesignal (Figure intensity 2a-e). of Thethe is[7]. varies This pancreaticfrom 0.55% tissue to 14% has itsat ductautopsy which [6]. drains The most into presenceadjacent normalof surrounding pancreatic fat parenchyma stranding, normalin all sequences, adjacent commonthe adjacent location bowel. of ectopic The incidencepancreatic ectopic tissue ispancreas around pancreas, and a clinical diagnosis of acute pancreatitis the pancreas (86%) like duodenum, stomach especially raised the possibility of acute ectopic pancreatitis. prepyloric antrum, and proximal jejunum [8]. It can also be seen in the ileum and Meckel’s diverticulum. symptomsImmediate subsided.surgery was potentially avoided and treated with conservative management for acute pancreatitis until asymptomatic and it is discovered incidentally at surgeryIndividuals or autopsy.with ectopic When pancreaticsymptomatic, tissue patients are tendusually to experience symptoms in the 4-6th decades [9]. The most Additionally, an upper endoscopy was performed 3 days common symptoms are abdominal pain, GI bleeding, and after the MRI study by gastroenterologist and identified theJOP. Journalcorresponding of the
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