0:01

Let's deal with another case here,

0:03

the same challenge, whether it

0:04

is a mass or it is pancreatitis.

0:08

So let me quickly scroll through and what we

0:11

see here, dilated intrahepatic bile ducts and

0:15

dilated CVD, but we are missing gallbladder.

0:19

So not having gallbladder means it can

0:22

be physiological after cholecystectomy.

0:26

As we go downwards, we see the

0:28

change of caliber in the CVD.

0:30

Here it becomes very small, see the size here.

0:33

And then we see some of the dilated ducts

0:37

inside the parenchyma of the pancreas or

0:40

a mass-like area in the pancreatic head.

0:44

As we follow this backwards,

0:46

we see lots of dilated side branches.

0:50

Like most of the pancreas is replaced by

0:52

dilated side branches and as we follow forward

0:57

proximally we see dilated pancreatic duct which

1:02

just disappears at the location of this mass.

1:05

So there is an abrupt cut off of both of the ducts.

1:09

There is a possible double duct sign,

1:12

but what we are seeing retained parenchyma,

1:14

dilated side branches, so now we are in

1:18

between the two, whether it is a mass

1:20

or whether it is a chronic pancreatitis.

1:23

As I said earlier, you can still develop a mass

1:26

or adenocarcinoma on the background of chronic

1:28

pancreatitis in about 2-3 percent of the patients.

1:31

Let's go coronal and try to

1:34

see that area one more time.

1:36

Ill-defined mass, double duct

1:38

sign, again maintained parenchyma

1:42

and the side branches are there.

1:44

Do we see penetrating duct sign here?

1:46

Possibly not.

1:48

It's questionable, but it is possibly not.

1:51

Let's go to the MRCP.

1:54

Nothing significant.

1:56

Going to pre-contrast T1-weighted images.

1:59

Nothing significant.

2:01

And now the key images are coming.

2:03

Those are post-contrast, and we have

2:04

to see whether this so-called mass or

2:08

pseudomass has involved the vessels or not.

2:11

So SMA looks grossly patent.

2:15

There is some dirtiness there in

2:19

the fat in the mesenteric route.

2:21

We do not see any retroperitoneal

2:22

lymphadenopathy anywhere.

2:23

There is no suspicious lesion in the liver so far.

2:29

Let's go to the venous phase and try to find if we

2:34

can see portal vein throughout its length or not.

2:40

So portal vein actually

2:41

disappears in this location.

2:43

And then we see lots of collaterals.

2:47

But can we have chronic pancreatitis

2:48

involving the portal vein?

2:50

Yeah, that is possible.

2:53

Can we take this as a reliable sign of mass?

2:54

Possibly not.

2:57

But the good thing is We'd never saw a

3:00

mass infiltrative along with the SMA.

3:05

What about celiac trunk?

3:09

If we go backwards and try to pick up celiac

3:12

trunk, this is the celiac trunk here and it

3:14

looks like very patent, very clean in outline.

3:18

This is the GDA arising from the common hepatic.

3:22

These are the left and right hepatic arteries.

3:25

All of them are looking very clean,

3:27

well-defined, no haziness, no compromised lumen.

3:32

Splenic artery also looks good.

3:34

SMA looks grossly fine.

3:36

So overall, arteries are fine, except the

3:38

SMV, which is compromised in caliber and

3:40

replaced by collateral surrounding that mass.

3:44

So probability here, here that we have a mass or

3:48

chronic pancreatitis, it is kind of controversial.

3:51

So you may actually deal with these kind

3:53

of cases in real life where we don't know

3:55

which, which, where we are going to lean for.

3:58

So more the science we have for a malignancy,

4:00

we can say it is confidently malignancy is present.

4:03

But if we have kind of both sides, in this

4:05

case what we are seeing there is double

4:07

duct sign, abrupt cutoff is present,

4:09

there is no duct-penetrating sign, but we have

4:11

no involvement of the vessels, and then

4:13

we see retained parenchyma in the duct.

4:16

So the ratio is more or less maintained.

4:19

So now in this particular case, we are

4:20

going to advise EUS-guided biopsy.

4:23

So this case we refer to the gastroenterologist,

4:26

they will enter through the stomach and they

4:28

will reach to the duodenum, and with fine needle

4:31

aspiration they will take some tissue out of

4:32

this. And confirm whether it was cancer or not.

4:35

In this case, actually, it was

4:37

proven to be chronic pancreatitis.