Gastrointestinal: Superinfection of a large cystic mucinous pancreatic neoplasm

Gastrointestinal: Superinfection of a large cystic mucinous pancreatic neoplasm An 82‐year‐old woman presented with 3 months of worsening abdominal pain and weight loss. Examination showed an epigastric mass. Labs revealed a neutrophilic leukocytosis. Computed tomography of abdomen showed a large multi‐loculated cystic mass with peripheral calcifications (Fig. ; arrowheads). There was non‐dependent air within the large inferior component (arrow). No bowel communication was appreciated that made the air pattern concerning for infection rather than erosion into the intestine.1Computed tomography abdomen/pelvis coronal view. Arrowhead depicts peripheral calcification. Arrow depicts non‐dependent air within the cyst.Endoscopic ultrasound with biopsy, transgastric drainage, and extensive necrosectomy was performed. Biopsy showed low‐grade mucinous neoplasm (Fig. ; arrow) concerning for either intraductal papillary mucinous neoplasm (IPMN) or mucinous cystic neoplasm (MCN). No ovarian stroma was present to indicate MCN. Cyst fluid culture grew polymicrobial organisms. Parenteral broad spectrum antibiotics were initiated with symptom improvement. Repeat imaging 1 week later showed decrease in the larger dominant air‐fluid cavity.2Pancreatic cyst wall biopsy . Arrow depicts low grade mucinous epithelium.This case highlights the insidious nature of cystic mucinous pancreatic neoplasms that can remain asymptomatic until large in size. Cyst infection of mucinous neoplasms is rare. The polymicrobial nature of the infection suggests possible transient fistulation between the cyst and the bowel with spontaneous resolution. There are limited data regarding management of infected mucinous pancreatic neoplasms. Drainage of the infected cyst along with antibiotic therapy and surgical resection has been reported to be effective. In our case, transgastric drainage and parenteral antibiotic therapy resulted in significant improvement in symptoms. Surgical resection was not pursued due to coexistent medical conditions, advanced age, poor nutritional status, patient preference, and large size of the lesion.Distinguishing MCNs from IPMNs can be a diagnostic challenge. MCNs are found predominantly in women and most arise in the pancreas body and tail. In contrast, IPMNs are gender neutral and usually originate in the pancreatic head or neck. Given the extremely large size of this patient's lesion, it was impossible to determine which part of the pancreas the neoplasm originated. Although MCNs are typically surrounded by ovarian‐like stroma and have epithelial layers with mucin‐producing cells, our patient's mass may have had these features in a part of the lesion that was not sampled. Our patient received 4 weeks of broad spectrum intravenous antibiotics and has been asymptomatic at 6‐month follow‐up. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Gastroenterology and Hepatology Wiley

Gastrointestinal: Superinfection of a large cystic mucinous pancreatic neoplasm

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Wiley Subscription Services, Inc., A Wiley Company
Copyright
© 2018 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd
ISSN
0815-9319
eISSN
1440-1746
D.O.I.
10.1111/jgh.13993
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Abstract

An 82‐year‐old woman presented with 3 months of worsening abdominal pain and weight loss. Examination showed an epigastric mass. Labs revealed a neutrophilic leukocytosis. Computed tomography of abdomen showed a large multi‐loculated cystic mass with peripheral calcifications (Fig. ; arrowheads). There was non‐dependent air within the large inferior component (arrow). No bowel communication was appreciated that made the air pattern concerning for infection rather than erosion into the intestine.1Computed tomography abdomen/pelvis coronal view. Arrowhead depicts peripheral calcification. Arrow depicts non‐dependent air within the cyst.Endoscopic ultrasound with biopsy, transgastric drainage, and extensive necrosectomy was performed. Biopsy showed low‐grade mucinous neoplasm (Fig. ; arrow) concerning for either intraductal papillary mucinous neoplasm (IPMN) or mucinous cystic neoplasm (MCN). No ovarian stroma was present to indicate MCN. Cyst fluid culture grew polymicrobial organisms. Parenteral broad spectrum antibiotics were initiated with symptom improvement. Repeat imaging 1 week later showed decrease in the larger dominant air‐fluid cavity.2Pancreatic cyst wall biopsy . Arrow depicts low grade mucinous epithelium.This case highlights the insidious nature of cystic mucinous pancreatic neoplasms that can remain asymptomatic until large in size. Cyst infection of mucinous neoplasms is rare. The polymicrobial nature of the infection suggests possible transient fistulation between the cyst and the bowel with spontaneous resolution. There are limited data regarding management of infected mucinous pancreatic neoplasms. Drainage of the infected cyst along with antibiotic therapy and surgical resection has been reported to be effective. In our case, transgastric drainage and parenteral antibiotic therapy resulted in significant improvement in symptoms. Surgical resection was not pursued due to coexistent medical conditions, advanced age, poor nutritional status, patient preference, and large size of the lesion.Distinguishing MCNs from IPMNs can be a diagnostic challenge. MCNs are found predominantly in women and most arise in the pancreas body and tail. In contrast, IPMNs are gender neutral and usually originate in the pancreatic head or neck. Given the extremely large size of this patient's lesion, it was impossible to determine which part of the pancreas the neoplasm originated. Although MCNs are typically surrounded by ovarian‐like stroma and have epithelial layers with mucin‐producing cells, our patient's mass may have had these features in a part of the lesion that was not sampled. Our patient received 4 weeks of broad spectrum intravenous antibiotics and has been asymptomatic at 6‐month follow‐up.

Journal

Journal of Gastroenterology and HepatologyWiley

Published: Jan 1, 2018

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