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Intraductal Papillary Mucinous Neoplasm of the Pancreas Presented with Dual, Gastric, and Duodenal Fish Mouth Sign


Alastal, Yaseen MD1; Hammad, Tariq MD2; Khalil, Basmah MD1; Ali, Fatema3; Khan, Muhammad Ali MD4; Nawras, Ali MD FACP FACG2

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American Journal of Gastroenterology: October 2016 - Volume 111 - Issue - p S526
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Introduction: Fistula formation is a rare potential complication of intraductal papillary mucinous neoplasm (IPMN) of the pancreas, most frequently involves duodenum, but gastric involvement is less common. Herein we describe a rare case of recurrent IPMN of the pancreas complicated by pancreaticogastric fistula. Case presentation: A 79-year-old female patient presented to the emergency department with epigastric abdominal pain radiating to the back for 1 day. Past medical history was significant for chronic pancreatitis, and history of IPMN for which she had distal pancreatectomy 12 years ago. At presentation, vital signs were stable. Abdominal examination showed no tenderness, guarding or rigidity. Bowel sounds were present. Laboratory work: WBC: 13 K/mm3, total bilirubin 0.5 mg/dL, alkaline phosphatase: 190 U/L, AST: 423 U/L, ALT: 213 U/L. Amylase and lipase were normal. Viral hepatitis serology was negative. MRCP showed worsening dilatation of pancreatic duct about 20 mm in diameter associated with stable intrahepatic and extrahepatic biliary dilatation. No clear cause of biliary obstruction was identified. Patient underwent endoscopic ultrasound for further evaluation of the pancreas. EGD/EUS revealed fistula tract noted at the lesser curvature of the gastric body with significant amount of thick gelatinous mucus pouring out of the fistula into the gastric lumen. The examination of the papilla also revealed significant amount of mucus flowing out of the major papilla into the duodenal lumen. Endosonographic examination revealed significant dilation of the pancreatic duct at the head and body of the pancreas with significant atrophy of the pancreatic parenchyma. The largest cystic dilation was noted at the head of the pancreas, which measured 26.1 mm x 23.0 mm. Examination of the site of the gastric fistula revealed cystic dilation measured 26.1 x 23.0 mm at the gastropancreatic fistula tract. Fine needle aspirations were performed from the cystic lesions. Pathology study showed IPMN with at least high grade dysplasia. The patient was referred to surgery clinic for further management. Conclusion: Pancreaticogastric fistula is a potential complication of IPMN which can result from direct invasion or mechanical penetration due to high pressure at the mucin filled pancreatic ducts.

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