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Case Presentation

Case Presentation. Abdominal pain 53 yo woman presents with acute epigastric pain radiates to her back associated with nausea & emesis No EtOH, trauma, new meds RA, HTN, Cholecystectomy, C/S. CC HPI PMH. Case Presentation. Remicade, Lodine, Altace, Methotrexate Codeine

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Case Presentation

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  1. Case Presentation Abdominal pain 53 yo woman presents with acute epigastric pain radiates to her back associated with nausea & emesis No EtOH, trauma, new meds RA, HTN, Cholecystectomy, C/S CC HPI PMH

  2. Case Presentation Remicade, Lodine, Altace, Methotrexate Codeine Married, 20 ppd, occ EtOH Negative Negative MEDS ALL SH FH ROS

  3. Case Presentation 226/110 84 20 98.6 NAD Anicteric CTA RRR with flow murmur Epigastric pain w/o R/G No c/c/e A&Ox3. Non-focal Vitals Gen HEENT Lungs Heart Abd Ext Neuro

  4. Case Presentation 1157 NL 16,900 13.1 9.7 4.4 20 0.8 96 Lipase LFTs WBC HGB Ca Alb BUN Cr Tri

  5. Case Presentation

  6. Pancreatic Cystic Neoplasms Rajeev Jain, M.D.

  7. Cystic Lesions of the Pancreas Congenital Cysts Acquired Cysts Primary Cystic Neoplasms Nonpancreatic Lesions Dermoid VHL Polycystic Simple Adrenal cyst Biloma Choledochal Choledochocele Diverticulum Duplication Mesenteric Retroperitoneal Splenic artery aneurysm Pseudocyst Parasitic Retention Levy MJ & Clain JE. Clin Gastroenterol Hepatol.2(8):639-53.2004.

  8. Mucinous Tumors Cystadenoma Cystadenocarcinoma Intraductal papillary mucinous tumor (IPMN) Nonmucin Tumors Serous cystadenoma Solid-pseudopapillary tumor Cystic degeneration Acinar cell cystadenocarcinoma Angiomatous tumor Angioma Hemangioma Lymphangioma Islet cell tumors Lymphoepithelial cyst Pancreaticoblastoma Teratoma Primary Pancreatic Cystic Neoplasms Levy MJ & Clain JE. Clin Gastroenterol Hepatol.2(8):639-53.2004.

  9. Epidemiology Brugge WR. et al. N Engl J Med.351:1218-26.2004.

  10. Serous Cystadenoma • Microcystic, serous, or glycogen-rich adenomas • Presentation • 50-60% have abdominal pain (up to 25 cm) • 30% palpable mass • Occ. obstructive jaundice, pancreatitis, pancreatic insufficiency, or gastric outlet obst. • 25% small & asymptomatic found on CT Levy MJ & Clain JE. Clin Gastroenterol Hepatol.2(8):639-53.2004.

  11. Serous Cystadenoma • Focal, well-demarcated lesions • Multiple (>6), small (<1-2 cm), fluid-filled microcysts • Dense fibrous septations give honeycomb appearance 8 mm Levy MJ & Clain JE. Clin Gastroenterol Hepatol.2(8):639-53.2004.

  12. Serous Cystadenoma Source: www.jichi.ac.jp

  13. WHO Classification Mucin-producing cystic neoplasms of the pancreas Intraductal Papillary Mucinous Neoplasm (IPMN) Mucinous cystadenoma Mucinous cystadenocarcinoma

  14. Mucinous Cystadenoma • Macrocystic adenoma • Premalignant • 25% contain malignancy at time of diagnosis • Presentation • Pain (60-80%) • Diabetes (25%) • Pancreatitis (10-20%) • Incidental (10-30%) • Ovarian stroma Grogan JR et al. AJR 176:921-9.2001. Levy MJ & Clain JE. Clin Gastroenterol Hepatol.2(8):639-53.2004.

  15. Ovarian Stroma

  16. Intraductal Papillary Mucinous Neoplasm (IPMN) Main Duct Variant Side Branch Variant Grogan JR et al. AJR 176:921-9.2001.

  17. IPMN • Presentation • Pain (50-100%) • Acute pancreatitis (22-45%) • Asymptomatic (up to 30%) • Variants • Main duct (47-75%) • Side branch (25-39%) • Both (14%) Levy MJ & Clain JE. Clin Gastroenterol Hepatol.2(8):639-53.2004.

  18. Evaluation of PCNs • 10-37% initially diagnosed erroneously as pseudocyst • Delay in diagnosis • Lost opportunity for curative resection • Type of PCN • Demographics • Radiology • EUS with FNA

  19. Imaging of PCNs Levy MJ & Clain JE. Clin Gastroenterol Hepatol.2(8):639-53.2004.

  20. Serous CystadenomaCT Findings Demos TC et al. AJR. 179:1375-1388.2002.

  21. IPMN and ERCP Aithal GP et al. Gastrointest Endosc.56(5):701-7.2002.

  22. Pancreatic Duct

  23. IPMN Histology

  24. Pancreatic Cyst Fluid Analysis Levy MJ & Clain JE. Clin Gastroenterol Hepatol.2(8):639-53.2004.

  25. Pancreatic Cyst Fluid Analysis • 19 pancreatic cystic masses, 31 pseudocysts • CA 19-9 > 50,000 U/mL • Sens 75%, Spec 90% • MCN > other cysts • CEA < 5 ng/mL • Sens 100%, Spec 86% • SCN > other cysts • Amylase > 5,000 U/mL • Sens 94%, Spec 74% • Pseudocysts > other cysts Hammel P. et al. Gastroenterology.108:1230-5.1995.

  26. Diagnosis of Pancreatic Cystic Neoplasms • Multicenter trial • 341 pts EUS-FNA • 112 pts surgical resection • Prospective evaluation: • EUS imaging, • Cyst fluid cytology, • Cyst fluid tumor markers • CEA, CA 72-4, CA 125, CA 19-9, and CA 15-3 Brugge WR. et al. Gastroenterology.126:1330-6.2004.

  27. Diagnosis of Pancreatic Cystic Neoplasms Accuracy • CEA • (88 of 111, 79%) • EUS morphology • (57 of 112, 51%) • Cytology • (64 of 109, 59%) Brugge WR. et al. Gastroenterology.126:1330-6.2004.

  28. Proposed Management Algorithm for Symptomatic PCNs Scheiman JM. Gastroenterology.128:463-9.2005.

  29. Proposed Management Algorithm for Asymptomatic PCNs Castillo, C. F.-d. et al. Arch Surg.138:427-34.2003.

  30. Pancreatic Cystic Neoplasm

  31. EUS Guided Cyst Aspiration Amylase CEA CA 19-9 93 906 1,890,000

  32. Pancreatic Cystic Neoplasm

  33. Pancreatic Cyst Amylase CEA CA 19-9 502 2.5 ----

  34. Case Presentation

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