Letter to the Editor
Groove pancreatitis. A benign entity simulating pancreatic head tumor
Pancreatitis del surco: entidad benigna simuladora de tumor de cabeza de páncreas
Marta Allue
, Teresa Ramírez, Agustín García Gil
Corresponding author
Servicio Cirugía General, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
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A benign entity simulating pancreatic head tumor" "tieneTextoCompleto" => true "saludo" => "Dear Editor:" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "204" "paginaFinal" => "205" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Marta Allue, Teresa Ramírez, Agustín García Gil" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Marta" "apellidos" => "Allue" "email" => array:1 [ 0 => "martitaallue@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Teresa" "apellidos" => "Ramírez" ] 2 => array:2 [ "nombre" => "Agustín" "apellidos" => "García Gil" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio Cirugía General, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Pancreatitis del surco: entidad benigna simuladora de tumor de cabeza de páncreas" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 700 "Ancho" => 1750 "Tamanyo" => 112264 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Abdominal CT: 8 cm mass adjacent to the head of the pancreas. (B) Endoscopic ultrasound: Image of possible duplication cyst vs. duodenal wall hematoma.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Groove or paraduodenal pancreatitis is a segmental form of chronic pancreatitis,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> which can mimic periampullary neoplasms.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We report two cases of difficult differential diagnosis in which surgery was indicated on suspicion of tumour pathology.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Case 1: 64-year-old man who presented with a 1-year history of epigastric pain and 5 kg weight loss. Laboratory tests showed cholestasis (GOT 65 U/L, GPT 82 U/L, GGT 1,834 U/L, AP 756 U/L) with normal bilirubin and CEA of 4.14 ng/mL, CA19.9 of 100 U/mL. On ultrasound, dilatation of intra-extrahepatic bile ducts due to a tumour measuring 9.5 × 4 × 7.5 cm in the theoretical site of the head of the pancreas was observed. CT scan showed an 8 cm tumour adjacent to the pancreatic head involving the second portion of the duodenum and papilla without any vascular involvement (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Gastroscopy showed an 8 mm ulcerated polyp in the second portion of the duodenum. Given the suspicion of pancreatic neoplasm, surgical intervention was indicated: tumour of the third portion of the duodenum surrounded by a large desmoplastic component, chronic liver disease and/or liver cirrhosis. In addition, multiple palpable polyps, and diffuse venous dilatations in the serosa of the jejunum widely distributed throughout the small intestine. A cephalic pancreaticoduodenectomy was performed.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The anatomical pathology report showed duodenal submucosal fibrosis extending to the pancreas, myoid cell proliferation, myofibroblasts in a storiform pattern, cystic ductal dilatation, focal acinar atrophy and sclerosis, endarteritis and chronic lymphoplasmacytic inflammatory infiltrate in aggregates, IGG4 +<50/agc plasma cells. Sinus histiocytosis in 28 isolated lymph nodes. Jejunal submucosal arteriovenous malformations with ischemic-necrotic changes were identified. All findings consistent with groove pancreatitis and Brunner’s gland hyperplasia.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Case 2: 53-year-old man, hypertension, polycythaemia, drinking habit and former cocaine user. The patient presented with a 6-month history of abdominal pain and vomiting. Admitted for intestinal obstruction secondary to extrinsic duodenal compression due to a paraduodenal mass of uncertain origin; duplication cyst vs. duodenal wall haematoma in imaging tests (abdominal ultrasound, CT scan, endoscopic ultrasound + FNA (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), gastroscopy and EGD), with a progressive reduction of the lesion in controls, together with gradual resolution of the symptoms. Two months later he was admitted for a new episode and the barium transit confirmed a 4–5 cm mass involving the second portion of the duodenum and surgical intervention was indicated.</p><p id="par0030" class="elsevierStylePara elsevierViewall">A cephalic pancreaticoduodenectomy was performed. Histology confirmed groove pancreatitis.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Groove pancreatitis was described in 1973 and classified into two forms, pure and segmental, depending on whether it only involved the groove or also the head of the pancreas. It occurs in men aged 40–50 years with a history of drinking and generally presents with epigastric pain and postprandial vomiting associated with weight loss, as a result of altered intestinal motility and duodenal stenosis, as well as jaundice secondary to compression of the common bile duct, symptoms that it shares with other entities such as pancreatic neoplasm, thus posing a difficult differential diagnosis.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Of uncertain pathogenesis, several associated factors such as peptic ulcers, gastric resection, duodenal cysts, and pancreatic heterotopia in the duodenum have been reported. For other authors, the presence of an abnormal Santorini’s duct is key, as it interrupts the outflow of pancreatic juice which flows back into the pancreatic body where it remains stagnant.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Histology reveals multiple dilated ducts and thickened secretion with pseudocystic changes, Brunner’s gland hyperplasia, and excess fibrosis in the groove.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Regarding diagnostic imaging, we identified a duodenal stenosis in the upper gastrointestinal transit and stenosis of the main pancreatic duct on ERCP. Endoscopic ultrasound is considered the technique of choice since it also allows obtaining material for histological study.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The CT scan identified a hypodense mass between the pancreatic head and the second portion of the duodenum and thickening of the duodenal wall with stenosis of the duodenal lumen. MRI showed a hypointense mass relative to the pancreatic parenchyma on T1 and isointense on T2 with delayed enhancement after gadolinium administration. Magnetic resonance cholangiography showed intrapancreatic common bile duct stenosis (in 67% of the pure forms and 27% of segmental forms) and sometimes Wirsung’s duct stenosis.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conclusion</span><p id="par0050" class="elsevierStylePara elsevierViewall">Differential diagnosis with tumours of the periampullary area is difficult, since they share radiological findings and, in many cases, the final diagnosis is histological after performing a pancreaticoduodenectomy.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of interests</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conclusion" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflict of interests" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Allue M, Ramírez T, Garcia Gil A. Pancreatitis del surco: entidad benigna simuladora de tumor de cabeza de páncreas. Med Clin (Barc). 2020. <span class="elsevierStyleInterRef" id="intr0005" href="https://doi.org/10.1016/j.medcli.2020.05.040">https://doi.org/10.1016/j.medcli.2020.05.040</span></p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 700 "Ancho" => 1750 "Tamanyo" => 112264 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Abdominal CT: 8 cm mass adjacent to the head of the pancreas. (B) Endoscopic ultrasound: Image of possible duplication cyst vs. duodenal wall hematoma.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Groove pancreatitis. A mini-series report and review of the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "A. Manzelli" 1 => "A. Petrou" 2 => "A. Lazzaro" 3 => "N. Brennan" 4 => "Z. Soonawalia" 5 => "P. 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