CLINICAL DIAGNOSIS: Suspected pancreatic head mass.
INDICATION FOR PROCEDURE: The patient is a (XX)-year-old gentleman with a long history of alcohol abuse, hospitalized with withdrawal symptoms. A CAT scan and ultrasound had demonstrated possible lesion in the head of the pancreas. He is undergoing an endoscopic ultrasound and evaluation on account of this.
PREMEDICATIONS AND OTHER MEDICATIONS:
1. Demerol 100 mg.
2. Versed 10 mg.
3. Phenergan 25 mg.
PROCEDURES PERFORMED:
1. EUS color flow Doppler study.
2. EUS-guided fine needle aspiration biopsy of a lymph node at the gastrohepatic ligament.
DESCRIPTION OF PROCEDURE: After informed consent, the patient was brought to the endoscopy unit and placed in the left lateral decubitus position. IV sedation was administered following which the gastroscope was passed under direct vision. Esophagus, stomach, and duodenum were examined with the gastroscope and found to be normal.
Next, the EG 3630UR radial echoendoscope was passed into the distal duodenum in the usual manner and multiple echo images, primarily using the 5 MHz transducer, were performed. The common bile duct and pancreatic head were clearly visualized. The common bile duct measured approximately 3.5 to 5 mm in size, as it is close to the head of the pancreas. The pancreatic head itself looked inhomogeneous with several echogenic areas suspicious for chronic pancreatitis. The portal veins and premesenteric veins were normal. The gallbladder wall appears slightly thick and otherwise did not show any abnormalities. The scope was withdrawn back into the stomach, and the pancreatic body was visualized from the proximal stomach. Again, marked inhomogeneity and echogenicity and hyperechoic borders of the pancreatic duct was clearly visualized. The pancreatic duct appeared to be slightly dilated. The portal veins and splenic veins confluence as well as celiac axis were otherwise normal. In the region of the gastrohepatic ligament area, at least 2 oval-shaped lymph nodes measuring about 6-7 mm in size each were noted and exhibited characteristics of benign disease. Color flow Doppler was used to study the mesenteric vasculature.
The radial echoendoscope was withdrawn following which the linear echoendoscope was passed in the usual manner, and the pancreas again was reexamined. Again, the pancreatic head demonstrated diffuse inhomogeneity, and no other abnormalities were seen. Common bile duct again was normal. The lymph node noted in the gastrohepatic ligament area was biopsied, and the procedure was terminated.
IMPRESSION:
1. Esophagogastroduodenoscopy was normal.
2. Endoscopic ultrasonography demonstrated changes involving the entry of pancreas suggestive of chronic pancreatitis. Lobulation, echogenicity and hyperechoic margins of pancreatic duct all indicated that the findings are probably related to chronic pancreatitis. Common bile duct, portal vein and splenic vein were all normal.
3. About 2-3 benign-appearing lymph nodes were noted in the gastrohepatic ligament area. Biopsies were obtained of one these lesions.
RECOMMENDATIONS:
1. Based on the above findings, we suspect that he may have chronic pancreatitis.
2. Await pathology. However, we do not expect to find any significant pathological diagnosis on this lymph node biopsy. A repeat triple phase CT of the pancreas in approximately 6-12 weeks may be warranted.
3. The patient will also need alcohol rehab.
