We described the indigestion caused by an involutive reduction in efficiency of intestinal digestion as a result of age-reduction enzymes of the pancreas, small intestine and stomach. Symptoms of involutive maldigestion eliminated fractional power, the use of pancreatic enzymes, pre- and probiotics.

A 26-year-old woman was evaluated for a mass found by computed tomography (CT). Radiographically, the mass resembled a pancreatic cystadenoma. The patient had had left upper quadrant abdominal pain for several years and low grade fevers and indigestion for 5 months. At surgery, a unilocular cystic mass was found anteriorly and caudally to the tail of the pancreas in the lesser sac. The cystic structure was connected to the pancreas by a tubular structure, which was suture ligated and divided. A review of the literature revealed this cyst to be the fifth reported case of enterogenous cyst of the pancreas. The case is unique, differing from previous reports in that ciliated respiratory epithelium, transitional epithelium, gastric mucosa, a bilayered smooth muscle wall, and a serosal surface were present in the cyst wall.

The macrocystic variant of serous cystadenomas of the pancreas has only recently been described. We present a case of a 40 year-old female, who presented with vague indigestion. The cyst was unilocular, and was lined by simple cuboidal, ciliated serous type epithelium. Fine needle aspiration, immunohistochemical, light microscopic, and electron microscopic studies are discussed.

Post-transplant patients reportedly have a higher risk of de novo neoplasms. However, intraductal papillary mucinous neoplasm (IPMN) of the native pancreas after pancreas transplantation (PTx) has not been well investigated. The choice of treatment, especially invasive treatment, for de novo neoplasms in transplant patients should consider their impaired immunity. In this context, we present a case of IPMN developing in the native pancreas of a PTx patient. A 53-year-old man underwent a follow-up abdominal computed tomography scan 6 years after a simultaneous pancreas-kidney transplant for type 1 diabetes mellitus with end-stage diabetic nephropathy requiring hemodialysis. The scan revealed IPMN in the pancreas head; an enhancing internal solid component suggested a high risk of malignancy, indicating surgical resection. Partial pancreatectomy or pancreaticoduodenectomy was anatomically indicated, but considering the insulin-secreting ability of the transplanted pancreas and the potential high risk of postoperative pancreatic fistula due to immune impairment after partial pancreatectomy, total pancreatectomy (TP) was performed. The patient is alive with good pancreas graft function, no signs of indigestion for 18 months after TP, and no evidence of IPMN recurrence. This report should help clinicians characterize de novo IPMN in the native pancreas and determine IPMN therapeutic options for transplant patients.

Keywords: Intraductal papillary mucinous neoplasm; Native pancreas; Pancreas transplantation; Total pancreatectomy.

BACKGROUND

Annular pancreas is a rare congenital anomaly. A ring of pancreatic tissue encircles the second part of the duodenum and results in varying degrees of obstruction. When the first symptoms occur in adults, they are non-specific and may consist in epigastric pain, fullness after meals, indigestion and nausea. Concomitant lesions such as ulcer or pancreatitis may obscure the diagnosis.

METHODS

A case report documents that radiologic examination with barium meal disclosed the duodenal stenosis.

RESULTS

A properly performed CT examination revealed the ring of pancreatic tissue which encircled the duodenum. Endoscopic retrograde pancreatography may show a duct with a characteristic circular pattern around the duodenum. MR and endoscopic ultrasonography are supplementary examinations in equivocal cases.

CONCLUSIONS

A CT examination is a good non-invasive primary examination when annular pancreas is suspected.

In a consecutive study of chronic alcoholics admitted for X-ray-negative dyspepsia, endoscopic retrograde pancreatography (ERP) showed pancreatographic changes in 47% of the patients, whereas exocrine pancreatic dysfunction was found in 19%. Only patients with severe parenchymatous damage on ERP had subnormal output of pancreas lipase. In patients with less severe pancreatographic changes the pancreas function test was normal. It was suggested that ERP is a more sensitive method for detection of minor and moderate duct abnormalities in pancreatic inflammatory disease. A clinical diagnosis of pancreatitis had been made in only 22% of the patients before the present investigation. Thus subclinical pancreatitis may be more frequent among alcoholics than previously recognized and should be suspected in cases of unclarified dyspepsia in patients with long-standing abuse of alcohol.

Metastatic solid pseudopapillary neoplasms of the pancreas are rare, and the stomach is also a rare site for metastases. We present a case of a lady with solid pseudopapillary neoplasm of the pancreas who previously had a distal pancreatectomy but subsequently had multiple hepatic, adrenal peritoneal and nodal metastases. She developed dyspepsia and on oesophagogastroduodenoscopy, was found to have gastric metastases as well. We believe this is the first reported case of metastatic solid pseudopapillary neoplasm of the pancreas to the stomach.

Dyspepsia is a common symptom among patients in family medicine practice. The prevalence in adult population is about 40%. Two-thirds of patients have functional dyspepsia. Clinical assessment, diagnostic procedures and treatment of patients depend on the age, symptoms and Helicobacter pylori infection. In patients with dyspepsia, it is necessary to assess the potential impact of other concurrent diseases and medications that the patient regularly uses. Prompt or early endoscopy is recommended in patients with newly detected dyspepsia older than 50 and presenting with alarming symptoms. In persons younger than 50, the recommended strategy is ‘test and treat’. In some patients, treatment is carried out by acid suppression. In patients failing to achieve success in treatment, further endoscopic diagnosis is indicated. Ultrasound diagnostics in primary care can significantly contribute to diagnostic evaluation and early treatment in patients with hepatobiliary and pancreas diseases presenting with symptoms of dyspepsia. Treatment of concurrent mental disorders can improve the symptoms of dyspepsia. Treatment of patients who do not respond to the recommended treatment strategies is a challenge for family physicians. Regular visits and psychotherapeutic support in these patients can reduce the level of anxiety and encourage the patient for treatment of psychological morbidity, as well as his efforts in healthy behavior.

Arteriovenous malformation (AVM) of the pancreas is an uncommon disease, which can cause an abdominal pain. This disease is characterized by a tangled vascular network, including the whole or part of the pancreas, resulting in portal hypertension by forming a shunt of the pancreas arteries to drain directly into the portal venous system. This study presents a case that was suspected as AVM of the pancreas by preoperative contrast-enhanced computed tomography scan (CT). A 49-year-old male patient had several episodes of abdominal discomfort associated with dyspepsia for 4 days. Magnetic resonance imaging showed enhancement of the conglomeration about 1.5 cm size in diameter in the pancreas. Selective angiography showed the proliferation of a vascular network in the pancreas and an early visualization of the portal vein during the arterial phase. Distal pancreatectomy with splenectomy was done. Histology of the pancreas showed AVM, with enzymatic fat necrosis extending to the capsule of the pancreas. The patient recovered successfully without postoperative complications. Surgical resection of pancreas is the definitive treatment for symptomatic AVM.

A 26-year-old man was referred to our department for a 3-year history of dyspepsia responsive to oral pump-inhibitors therapy. During the last year, he underwent a gastroscopy, a colonoscopy and a computed tomography enterography that failed to reveal an underlying organic disease: a diagnosis of functional dyspepsia was made. Because of the persistence of symptoms, he came to our ambulatory where we performed an abdominal ultrasound that revealed the presence of multiple bi-lobar lesions of the liver suspected for metastases and a hypoechoic solid lesion of the pancreas body, confirmed by a contrast enhanced computed tomography. Laboratory tests showed high chromogranin A and gastrin level, and a liver biopsy was consistent with a metastatic pancreatic neuroendocrine tumor. This report aims to underlie the diffuse heterogeneous diagnostic management of some common gastrointestinal symptoms, such as dyspepsia, that are too often approached with the prescription of proton pump inhibitors.

Ectopic pancreas is an uncommon congenital anomaly, which is usually found incidentally in clinical practice. It presents with nonspecific gastrointestinal symptoms like epigastric pain and dyspepsia and rarely with the clinical findings of obstructive jaundice or intestinal obstruction, or it may mimic gastrointestinal system cancer. Herein, we describe a case of ectopic pancreas in the duodenum, which was the cause of the intractable diarrhea. In our patient, upper gastrointestinal endoscopy and endoscopic ultrasonography revealed a 1.5 cm submucosal lesion, which was umbilicated centrally with a normal in appearance overlying mucosa. Endoscopic biopsy of the lesion was normal. Pathological examination of the lesion after surgical excision was compatible with ectopic pancreas. After total excision of the lesion, the clinical findings of the patient normalized. Ectopic pancreas presenting with diarrhea has not been reported previously in the literature.

Heterotopic pancreas (HP) is a relatively infrequent lesion most often found in the stomach. In the majority of cases, HP does not cause symptoms, but it can occasionally present as dyspepsia and upper gastrointestinal bleeding. This report describes the case of a 40-year-old man with gastric outlet obstruction resulting from HP in gastric antrum.

Solid and papillary neoplasms of the pancreas, a rare tumor usually found in young female patients, seldom presents with metastasis since it is a tumor with low potential for malignancy. The prognosis for this lesion is much more favorable than that for other pancreatic neoplasms. In an attempt to understand the characteristics and prognosis of this lesion, we reviewed twenty cases treated at the Department of Surgery, Severance Hospital, Yonsei University from 1985 to 1994. The mean age of the patients was 25.6 years (range: 13 to 39 years), and 19 (95%) were women. Chief complaints were palpable mass (50%), pain (45%), and indigestion (5%). In laboratory studies, tumor markers, including CEA, CA125, CA19-9, and aFP were studied in eight patients, and found negative. Other laboratory findings were also nonspecific. These tumors may occur anywhere in the pancreas. In our studies, the tumor was most often located in the tail (45%), and the head (40%) of the pancreas. These were treated by distal pancreatectomy and splenectomy (55%), Whipple's operation (20%), pylorus preserving pancreatoduodenectomy (10%), enucleation (10%) or excision (5%). Significant morbidity or mortality was not observed during hospitalization, and no recurrence or malignant degeneration occurred during the mean follow-up period of 4 years (range: 1 month to 9 years). In conclusion, this study has suggested that the patients with a solid and papillary neoplasm of the pancreas have a good prognosis for successful treatment, if the disease is diagnosed early and the tumor is completely resected. A higher index of suspicion, and more aggressive diagnostic workups are needed in dealing with this disease entity.

BACKGROUND

The so called post-cholecystectomy syndrome is common, intractable, often progressive, causes prolonged suffering, and has no approved treatment. It usually presents with episodic biliary pains (colics), and postprandial dyspepsia (bloating and indigestion). Because treating a very recalcitrant case with lovastatin provided prolonged remission, 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors were given to 12 subsequent patients with similar symptoms.

OBJECTIVE

To determine whether HMG-CoA reductase inhibitors are useful in the therapy of post-cholecystectomy biliary pain and dyspepsia.

METHODS

Open clinical trial in an internal medicine, private practice setting; data were collected from the patients' charts and from telephone interviews, five years after the index case had been treated.

RESULTS

Eight of 12 patients experienced total resolution of their symptoms after many years of suffering; response occurred slowly within the first three months of treatment. Two other patients responded, stopped their medications, relapsed, and continue to be symptomatic. One patient did not take her medication and remains symptomatic; one other patient did not respond, was diagnosed with carcinoma of the pancreas, and died from it.

CONCLUSIONS

These preliminary results suggest that HMG-CoA reductase inhibitors may be useful in relieving the symptoms of this common and intractable disorder. Controlled studies are needed.

Palliative treatment is appropriate for most patients with cancer of the head of pancreas. Insertion of a biliary stent relieves jaundice and pruritus but it is not known if stenting affects other symptoms or changes the quality of life. Nineteen patients have completed a standard questionnaire to assess symptom relief and quality of life after stent insertion. After stenting there was complete relief of jaundice and pruritus. Furthermore, there was also considerable improvement in anorexia and indigestion. All patients had anorexia before stent insertion, this was moderate/severe in 13 (68.4%). Anorexia was significantly better (p < 0.01) a week after stenting and this benefit was maintained at 12 weeks (p < 0.01). Sixteen (84.2%) patients complained of indigestion before stenting, moderate/severe in 11 (57.9%). This was significantly better (p < 0.01) a week after stenting with complete relief in six at eight weeks (p < 0.01). Fifteen (78.9%) felt that their mood was good/very good before stent insertion and this was unchanged even at the 12 week assessment. A similar result was obtained for physical health and level of activity. In conclusion stent insertion not only relieves jaundice and pruritus in these patients but also improves other symptoms and quality of life. The considerable improvement in appetite after stenting was of particular benefit.

The authors describe 6 children with pancreas ectopy to the gastric wall. Their age was between 8 and 14 years. The main clinical and endoscopic signs were: prolonged pain, dyspepsia and a "polyp" in pyloroantral part of the stomach. In 4 of 6 children the pancreas ectopy to the gastric wall was suspected. All patients had been operated on. The indications for surgery were the following: severe pain with no effect of conservative therapy, suspicion for "polyp" malignancy and ulceration, bleeding. In one patient Bilroth-1 resection has been performed and in 2 cases sectoral dissection of the gastric wall pancreatic ectopy has been done. In 3 patients enucleation of the ectopic pancreas was performed. All patients had ineventful postoperative period. The pancreas ectopy in children is an indication for the surgery because of severe pain and possibility of severe complications. The surgery relieves pain and provides recovery.

We report a 57-year-old man who presented with a two-month history of persistent epigastric pain associated with indigestion, weight loss and jaundice. Contrast-enhanced computed tomography revealed a large pseudoaneurysm 87 mm x 68 mm in diameter, with its origin from the inferior pancreaticoduodenal artery of the superior mesenteric artery and in continuity with an ectatic gastroduodenal artery. The aneurysmal mass exerted direct pressure over the head of the pancreas, common bile duct and duodenum, causing obstruction. Non-selective abdominal angiography confirmed the aneurysm stemming from the inferior pancreaticoduodenal artery. Because of the obstructive symptoms and the size of the aneurysm, surgery was planned, but the patient refused and died from massive gastrointestinal bleeding one month later.

Somatostatinomas are rare pancreatic endocrine neoplasms (PEN). We present a case of a PEN in a 63-year-old lady having diabetes mellitus, cholelithiasis, steatorrhea, weight loss, indigestion, nausea and fatigue. Ultrasonography revealed a large calcified mass occupying the liver, pancreas and emboli in the splenic vein. Fine needle aspiration cytology (FNAC) of the metastatic mass in the liver showed features of neuroendocrine tumor. Correlating the clinical picture, computed tomography and cytological findings, a diagnosis of pancreatic somatostatinoma was suggested. Serum somatostatin levels and biopsy findings confirmed the same. The patient was put on chemotherapeutic agents and octreotide and is doing well after two years of follow-up. We discuss the FNAC findings of pancreatic endocrine tumors and its differentiating features from hepatoma and other small round cell tumors.

Annular pancreas is a rare embryonal abnormality. Its manifestation in adulthood is often pinpointed with a substantial delay, which is most often attributed to pancreatitis, biliary pathology or dyspepsia. We present a case of a 28-year-old woman who had exacerbating symptoms of high bowel obstruction from 20th week of pregnancy, progressing after premature delivery. Diagnostic work-up revealed partial annular pancreas compressing the duodenum. Despite attempts of conservative treatment, her state deteriorated to such an extent that surgery was indicated and gastrojejunal bypass created. Her postoperative recovery was uneventful. In cases in which symptoms of high bowel obstruction in pregnancy persist and prostration occurs, we suggest close monitoring and a more thorough diagnostic approach. The question remains whether annular pancreas presents a cause of pathologic findings, a cofactor, or a mere accidental diagnosis in the development of superposed pathologies.

Somatostatinoma is one of the rarest tumours of the endocrine pancreas. Cardinal manifestations of a somatostatinoma include gallstones, mild diabetes mellitus, steatorrhoea, diarrhoea and dyspepsia. Like any other pancreatic islet cell carcinoma, a somatostatinoma may also produce several different hormones such as adrenocorticotropic hormone, calcitonin, vasoactive intestinal polypeptide, pancreatic polypeptide, gastrin, insulin, and glucagon. In many cases, the clinical picture is dominated by the effect of these other hormones. We present a patient with somatostatinoma in which an immunocytochemical study of the specimens from pancreas and liver showed a weak positive reaction for gastrin besides a strong positive reaction for somatostatin. Interestingly, this patient also showed the signs of carcinoid syndrome which was successfully treated with octreotide.

Minor degrees of pancreatic insufficiency may go unrecognized. There is a paucity of symptoms and physical findings in mild and moderate degrees of insufficiency and in such circumstances laboratory methods are necessary to determine the presence of insufficiency. The clinical picture when insufficiency is well established may be characterized by loss in weight; vague indigestion; voluminous, light-colored, glistening stools in which fat globulets may be seen; changes in the concentration of pancreatic enzymes in the blood indicative of lowered pancreatic function; diminished amounts of pancreatic enzymes in the duodenal juice, and the related poor digestion of fat and protein in the food. Lowered tolerance of carbohydrate, as found in diabetes mellitus, may or may not be present. The location and character of the disease in the pancreas causing the insufficiency may or may not be apparent.

This paper describes a 6-year-old Simmental bull with diabetes mellitus. The animal was referred to our clinic because of severe weight loss and chronic indigestion. Clinical examination revealed markedly disturbed general condition, impaired forestomach function and polyuria. There was aciduria, glucosuria and ketonuria. The most important biochemical findings were severe hyperglycemia, markedly increased activities of hepatic enzymes and severe metabolic acidosis. Plasma concentrations of insulin, insulin-like growth factor-I, thyroxine and 3,5,3'-triiodothyronine were lower than normal, whereas those of glucagon were higher than normal. Based on these findings, a diagnosis (secondary) diabetes mellitus was made. The bull was slaughtered and histological examination revealed mixed cell pancreatitis with severe degeneration of islet cells. Immunohistochemical examination of the pancreas showed that very few insulin-, glucagon-, somatostatin- and pancreatic polypeptide, insulin-like growth factor-I and adrenomedullin-producing islet cells were present.