Case 3
A 35-year-old male with no known co-morbids, presented with the
complaints of epigastric pain for 2 days. On examination the abdomen was
mildly tender in the epigastric region otherwise soft and without
rebound tenderness. The rest of the examination was unremarkable. Early
laboratory investigations including complete blood count, lipase,
amylase, and liver function tests were within the normal range (Serum
amylase was at the upper limit of normal). CT abdomen with contrast
showed a mildly enhancing soft tissue density mass involving the head
and uncinate process of the pancreas completely encasing the superior
mesenteric artery. Mild peripancreatic fat stranding and inflammatory
changes extending into the mesentery along with prominent peripancreatic
lymph nodes were also noted. Scan was concluded as acute on chronic
pancreatitis. The possibility of intraductal papillary mucinous tumor
was also raised. His serum CA19-9 (non-detectable to 39 U/mL) and CEA
(0-3.0 ng/mL healthy subjects) were 162 and 2.25 respectively.
Endoscopic retrograde cholangiopancreatography (ERCP) showed filling
defects in the distal common bile duct (CBD) consistent with sludge. CBD
was cleared from the sludge with repeat cholangiogram showing no filling
defect. Pancreatic duct could not be cannulated. The patient was
discharged in a stable condition. CT abdomen performed 4 years later
redemonstrated the same findings with interval progression. This time
the infiltrating lesion was seen encasing the portal vein and hepatic
artery (Figure 3 ). The conclusion of the scan was neoplastic
lesion with remote possibility of IgG4 related disease. CT guided
transhepatic core biopsy of the pancreatic lesion was performed.
Histopathology reported linear cores of fibrocollagenous tissue
exhibiting dense mixed inflammation with small abscesses and no evidence
of malignancy (Figure 4 ). Serum IgG-4 level was 2960 mg/L.
Patient has not paid a follow up visit after this.