Scientific letter
Groove Pancreatitis in the Differential Diagnosis of Pancreatic Adenocarcinoma
Pancreatitis del surco en el diagnóstico diferencial del adenocarcinoma de páncreas
Antonio Palomeque Jiménez
, Beatriz Pérez Cabrera, Francisco Navarro Freire, José Antonio Jiménez Ríos
Corresponding author
Servicio de Cirugía General y del Aparato Digestivo, Unidad de Cirugía Hepatobiliopancreática, Hospital Universitario San Cecilio, Granada, Spain
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Pancreatitis is one of the diseases that can affect this anatomical area. It was described for the first time in 1973 by Becker and Bauchspeinchel<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and, in 1982, Stolte et al. coined the term <span class="elsevierStyleItalic">groove pancreatitis</span>. It is a rare entity characterized by chronic segmental<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> pancreatitis and has an uncertain pathogenesis.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Its identification is important due to the diagnostic problems that may arise with other serious diseases that affect the head of the pancreas, such as pancreatic cancer.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a 42-year-old woman with a history of thrombophilia and a heavy drinking habit who, in August 2011, complained of continuous epigastric abdominal pain radiating to both hypochondria during the previous 5 months. The pain had worsened in the last week and was accompanied by postprandial heaviness, vomiting, intermittent 38<span class="elsevierStyleHsp" style=""></span>°C fever and weight loss. On examination, the patient showed only mild fever and epigastric tenderness.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The lab work only showed alterations in hemoglobin (11.3<span class="elsevierStyleHsp" style=""></span>g/dl) and leukocyte (15.000/μl) levels, with elevated PCR. Tumor markers CEA and CA 19.9 were normal.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Abdominal computed tomography (CT) revealed a mass measuring 50<span class="elsevierStyleHsp" style=""></span>mm×65<span class="elsevierStyleHsp" style=""></span>mm in the head of the pancreas/uncinate process that seemed to encompass the duodenum, along with increased density of the perilesional fat and retroperitoneal lymphadenopathies. Upper gastrointestinal endoscopy showed no lesions. Endoscopic ultrasound, however, revealed extrinsic compression in the second part of the duodenum with normal mucous membranes and a heterogeneous echogenic mass with irregular edges in the head of the pancreas/uncinate process. Fine-needle aspiration reported an inflammatory process. Magnetic resonance imaging (MRI) confirmed the CT findings. The possibility of an autoimmune process was ruled out, as antibodies (antinuclear, anti-lactoferrin, anti-neutrophil cytoplasmic PR3 and MP0) and immunoglobulin (IgG, IgG4, IgA and IgM) were within normal ranges.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The patient was symptomatic after hospital discharge and, given the suspicion of an inflammatory process, and was monitored with periodical follow-up analyses and radiological studies, which continued to indicate an inflammatory process.</p><p id="par0030" class="elsevierStylePara elsevierViewall">One year after hospitalization, the patient once again presented similar symptoms, with minimal elevation of serum amylase (203<span class="elsevierStyleHsp" style=""></span>U/l). CT confirmed the previous findings, and the patient was discharged after improvement in the symptoms.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Three months later, an MRI study showed a solid-cystic heterogenous mass measuring 7.6<span class="elsevierStyleHsp" style=""></span>mm between the head of the pancreas and the duodenum; it was hypointense in sequence T1 and hyperintense in sequence T2, with no contrast uptake. Residual inflammatory changes were also observed in the pancreaticoduodenal space as well as wall thickening of the second part of the duodenum, consistent with focal groove pancreatitis (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">With the diagnosis of groove pancreatitis, symptomatic treatment and abstinence from alcohol were continued, and the patient remains asymptomatic to date.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Groove pancreatitis is a relatively unknown presentation of chronic pancreatitis, which consists of the appearance of fibrous-scar tissue in the fatty plane of the pancreaticoduodenal groove. It most frequently affects middle-aged men with a history of alcoholism.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Two types have been described (pure and segmental) according to whether only the groove is affected or whether the dorso-cranial part of the head of the pancreas is affected as well.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Symptoms include postprandial abdominal pain, vomiting, weight loss and, less frequently, jaundice.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The pathogenesis is uncertain, and different causes have been proposed: peptic ulcer, gastric resection, duodenal wall cysts, presence of heterotopic pancreas in the duodenal wall and anatomical variations in the region of the minor papilla, associated with high alcohol consumption, which would increase the density of the pancreatic fluid and its proteins.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Diagnosis is based on clinical suspicion and different diagnostic tests. For many authors, endoscopic ultrasound is the diagnostic test of choice as it has greater sensitivity (86%) and specificity than conventional abdominal ultrasound and biopsies can be taken.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Gastroesophageal studies and upper gastrointestinal endoscopy are also useful as they are able to identify duodenal stenosis, and ERCP can display mild stenosis of the main pancreatic duct. CT usually identifies a mass with laminar morphology between the head of the pancreas and the second part of the duodenum that is hypodense with enhancement after administering contrast, although the findings are not completely specific. MRI generally locates a laminar mass in the pancreaticoduodenal groove that is hypointense compared with the pancreatic parenchyma in T1 and isointense or mildly hyperintense in T2, with delayed enhancement after administering gadolinium,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> as occurred in our case.</p><p id="par0065" class="elsevierStylePara elsevierViewall">According to Gabata et al.,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> the differential diagnosis between groove pancreatitis and adenocarcinoma cannot be done exclusively with CT and MRI studies. This is especially true if there are no cysts within the mass or in the thickened walls of the duodenum, requiring duodenal biopsy or arteriography. In our case, the diagnosis was based on clinical suspicion after a biopsy taken with endoscopic ultrasound that suggested an inflammatory process. MRI images later confirmed the groove pancreatitis.</p><p id="par0070" class="elsevierStylePara elsevierViewall">In pure forms, the differential diagnosis should be made with cholangiocarcinoma and acute pancreatitis with abscess in the area of the groove. The segmental form requires differential diagnosis with pancreatic adenocarcinoma, which is difficult but of great importance; in some cases, the differential diagnosis is only achieved after pancreaticoduodenectomy.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Conservative therapy based on analgesics, pancreatic rest and abstinence from alcohol are the mainstays of groove pancreatitis treatment. These measures usually succeed initially and must be regularly re-evaluated according to the symptoms, imaging studies and lab determinations.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,6,8,9</span></a> On occasion, the symptoms are resistant to medical treatment and surgical intervention may be required. Pancreaticoduodenectomy is the procedure of choice,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> and there are case reports of resection of the head of the pancreas with duodenal preservation<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> or even bypass in high-risk patients.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Surgery may be necessary if it is not possible to definitively rule out pancreatic cancer.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Palomeque Jiménez A, Pérez Cabrera B, Navarro Freire F, Jiménez Ríos JA. Pancreatitis del surco en el diagnóstico diferencial del adenocarcinoma de páncreas. Cir Esp. 2014;92:127–129.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 666 "Ancho" => 1001 "Tamanyo" => 73206 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">MRI image (sequence T1) showing a hypointense cystic lesion in the head of the pancreas.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 642 "Ancho" => 1001 "Tamanyo" => 74638 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">MRI image (sequence T2) showing a hyperintense lesion.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pancreatic adenocarcinoma that mimics groove pancreatitis: case report of a disgnostic dilema" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "C.H. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 17 | 2 | 19 |
| 2024 September | 56 | 5 | 61 |
| 2024 August | 38 | 7 | 45 |
| 2024 July | 27 | 1 | 28 |
| 2024 June | 24 | 8 | 32 |
| 2024 May | 37 | 6 | 43 |
| 2024 April | 31 | 19 | 50 |
| 2024 March | 36 | 5 | 41 |
| 2024 February | 42 | 2 | 44 |
| 2024 January | 49 | 3 | 52 |
| 2023 December | 58 | 2 | 60 |
| 2023 November | 58 | 5 | 63 |
| 2023 October | 61 | 22 | 83 |
| 2023 September | 38 | 1 | 39 |
| 2023 August | 30 | 0 | 30 |
| 2023 July | 70 | 6 | 76 |
| 2023 June | 48 | 1 | 49 |
| 2023 May | 129 | 7 | 136 |
| 2023 April | 99 | 2 | 101 |
| 2023 March | 101 | 13 | 114 |
| 2023 February | 64 | 6 | 70 |
| 2023 January | 66 | 11 | 77 |
| 2022 December | 124 | 14 | 138 |
| 2022 November | 68 | 20 | 88 |
| 2022 October | 58 | 10 | 68 |
| 2022 September | 53 | 20 | 73 |
| 2022 August | 59 | 21 | 80 |
| 2022 July | 53 | 18 | 71 |
| 2022 June | 58 | 13 | 71 |
| 2022 May | 69 | 11 | 80 |
| 2022 April | 68 | 13 | 81 |
| 2022 March | 126 | 11 | 137 |
| 2022 February | 111 | 6 | 117 |
| 2022 January | 106 | 14 | 120 |
| 2021 December | 81 | 21 | 102 |
| 2021 November | 78 | 16 | 94 |
| 2021 October | 58 | 24 | 82 |
| 2021 September | 55 | 37 | 92 |
| 2021 August | 68 | 10 | 78 |
| 2021 July | 49 | 15 | 64 |
| 2021 June | 50 | 14 | 64 |
| 2021 May | 71 | 15 | 86 |
| 2021 April | 186 | 13 | 199 |
| 2021 March | 132 | 16 | 148 |
| 2021 February | 76 | 16 | 92 |
| 2021 January | 70 | 14 | 84 |
| 2020 December | 53 | 10 | 63 |
| 2020 November | 70 | 10 | 80 |
| 2020 October | 52 | 14 | 66 |
| 2020 September | 34 | 16 | 50 |
| 2020 August | 63 | 7 | 70 |
| 2020 July | 67 | 19 | 86 |
| 2020 June | 48 | 15 | 63 |
| 2020 May | 61 | 16 | 77 |
| 2020 April | 55 | 6 | 61 |
| 2020 March | 58 | 5 | 63 |
| 2020 February | 64 | 8 | 72 |
| 2020 January | 83 | 14 | 97 |
| 2019 December | 85 | 11 | 96 |
| 2019 November | 59 | 12 | 71 |
| 2019 October | 36 | 4 | 40 |
| 2019 September | 34 | 3 | 37 |
| 2019 August | 34 | 9 | 43 |
| 2019 July | 43 | 12 | 55 |
| 2019 June | 103 | 23 | 126 |
| 2019 May | 238 | 17 | 255 |
| 2019 April | 79 | 13 | 92 |
| 2019 March | 20 | 16 | 36 |
| 2019 February | 29 | 7 | 36 |
| 2019 January | 19 | 1 | 20 |
| 2018 December | 24 | 1 | 25 |
| 2018 November | 25 | 2 | 27 |
| 2018 October | 41 | 5 | 46 |
| 2018 September | 28 | 3 | 31 |
| 2018 August | 9 | 0 | 9 |
| 2018 July | 12 | 2 | 14 |
| 2018 June | 16 | 2 | 18 |
| 2018 May | 15 | 2 | 17 |
| 2018 April | 18 | 2 | 20 |
| 2018 March | 8 | 0 | 8 |
| 2018 February | 7 | 1 | 8 |
| 2018 January | 18 | 5 | 23 |
| 2017 December | 12 | 0 | 12 |
| 2017 November | 13 | 1 | 14 |
| 2017 October | 24 | 1 | 25 |
| 2017 September | 13 | 3 | 16 |
| 2017 August | 14 | 2 | 16 |
| 2017 July | 26 | 4 | 30 |
| 2017 June | 32 | 3 | 35 |
| 2017 May | 44 | 1 | 45 |
| 2017 April | 28 | 2 | 30 |
| 2017 March | 34 | 8 | 42 |
| 2017 February | 43 | 6 | 49 |
| 2017 January | 48 | 4 | 52 |
| 2016 December | 41 | 5 | 46 |
| 2016 November | 33 | 6 | 39 |
| 2016 October | 52 | 19 | 71 |
| 2016 September | 101 | 13 | 114 |
| 2016 August | 43 | 4 | 47 |
| 2016 July | 48 | 2 | 50 |
| 2016 June | 42 | 8 | 50 |
| 2016 May | 47 | 7 | 54 |
| 2016 April | 41 | 8 | 49 |
| 2016 March | 35 | 15 | 50 |
| 2016 February | 21 | 10 | 31 |
| 2016 January | 30 | 12 | 42 |
| 2015 December | 47 | 8 | 55 |
| 2015 November | 37 | 6 | 43 |
| 2015 October | 42 | 5 | 47 |
| 2015 September | 19 | 9 | 28 |
| 2015 August | 44 | 6 | 50 |
| 2015 July | 45 | 5 | 50 |
| 2015 June | 20 | 3 | 23 |
| 2015 May | 22 | 5 | 27 |
| 2015 April | 12 | 7 | 19 |
| 2015 March | 25 | 4 | 29 |
| 2015 February | 15 | 4 | 19 |
| 2015 January | 30 | 7 | 37 |
| 2014 December | 39 | 12 | 51 |
| 2014 November | 26 | 7 | 33 |
| 2014 October | 28 | 6 | 34 |
| 2014 September | 18 | 4 | 22 |
| 2014 August | 31 | 4 | 35 |
| 2014 July | 33 | 5 | 38 |
| 2014 June | 20 | 9 | 29 |
| 2014 May | 17 | 7 | 24 |
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