Identification of intraductal papillary mucinous neoplasm by esophagogastroduodenoscopy

Some reports have described identification of intraductal papillary mucinous neoplasm (IPMN) penetrating to the stomach by esophagogastroduodenoscopy (EGD) [1] [2] [3] [4]. However, it seems that detecting an IPMN from within a postoperative pancreatogastric fistula is very rare.

A 71-year-old man presented with slight fever. He had a history of acute pancreatitis and underwent cystogastrostomy for pancreatic pseudocyst at another institution 8 years earlier. IPMN had not been detected at that time. A detailed examination was carried out, including computed tomography (CT), which revealed a large cystic tumor of the pancreatic head accompanied by a pancreatogastric fistula ([Fig. 1]). Dilatation of the main pancreatic duct was not evident on magnetic resonance cholangiopancreatography ([Fig. 2]). EGD also showed a fistula on the posterior side of the antrum ([Fig. 3]). On passing the scope through the fistula a protruding papillary tumor covered with mucus was noted ([Fig. 4]). Biopsy samples were obtained and histological examination revealed high-grade tubular adenoma. Pancreatoduodenectomy was subsequently carried out and the patient was diagnosed as having branch-type IPMN containing foci of well-differentiated tubular adenocarcinoma ([Fig. 5]). There was no evidence of local invasion or metastasis.

Fig. 1 Contrast-enhanced computed tomography (CT) in a 71-year-old man with mild fever and a history of acute pancreatitis. There is a large cystic tumor in the head of the pancreas. A pancreatogastric fistula is present within the posterior wall of the stomach.

Fig. 2 Magnetic resonance cholangiopancreatography showing cystic tumor in the head of the pancreas without dilatation of the main pancreatic duct.

Fig. 3 Endoscopic view of the pancreatogastric fistula.

Fig. 4 Endoscopic views. a After passage through the fistula. b Tumor after irrigation.

Fig. 5 Histological section of the resected specimen showing a well-differentiated tubular adenocarcinoma.

Endoscopy_UCTN_Code_CCL_1AZ_2AB

• References

• 1 Kobayashi G, Fujita N, Noda Y et al. Study of cases of mucin producing tumors of the pancreas showing penetration of other organs. Jpn J Gastroenterol 1993; 90: 3081-3089
• 2 Jung IS, Shim CS, Cheon YK et al. Invasive intraductal papillary mucinous tumor of the pancreas with simultaneous invasion of the stomach and duodenum. Endoscopy 2004; 36: 186-189
• 3 Masaru K, Naohiro S, Koji Y et al. Post ERCP pancreatogastric fistula associated with an intraductal papillary-mucinous neoplasm of the pancreas – a case report and literature review. World J Surg Oncol 2005; 3: 70-74
• 4 Kim JY, Kang DH, Kim GH et al. Malignant intraductal papillary mucinous neoplasm of the pancreas with multiple pancreatogastric fistulas: a report of 2 cases with different features. Gastrointest Endosc 2007; 66: 854-857