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Kim, Seo, Kang, Kim, Oh, Cho, Kim, Ji, Jeong, and Park: Pyogenic Pancreatic Abscess Mimicking Pancreatic Neoplasm: A Four-Case Series
Case Report

Korean J Gastroenterol 2015;65(4):252-257.

Published online: 4 October 2015

DOI: https://doi.org/10.4166/kjg.2015.65.4.252

Pyogenic Pancreatic Abscess Mimicking Pancreatic Neoplasm: A Four-Case Series

Mi Jin Kim, Euikeun Seo1, Eun Seok Kang, Keun Mo Kim, Young Min Oh, Byung Ha Cho, Hyung-Woo Kim, Myoung Jin Ji, Ji Won Jeong, Seon Mee Park

Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea

1Department of Internal Medicine, Hana General Hospital, Cheongju, Korea

Correspondence to: Seon Mee Park, Department of Internal Medicine, Chungbuk National University Hospital, 776, 1sunhwan-ro, Seowon-gu, Cheongju 362-711, Korea. Tel: +82-43-269-6019, Fax: +82-43-273-3252, E-mail: smpark@chungbuk.ac.kr

Received 27 July 201422 September 2014       Accepted 29 September 2014

Copyright © 2015 Korean Ophthalmological Society

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

A pyogenic pancreatic abscess mimicking pancreatic neoplasm in the absence of acute pancreatitis is rare. We report four patients who each presented with a pancreatic mass at the pancreas head or body without acute pancreatitis. The presenting symptoms were abdominal pain, fever, or weight loss. Abdominal CT scans showed low-density round masses at the pancreas head or body with/without lymphadenopathy. In each case, a PET-CT scan showed a mass with a high SUV, indicating possible malignancy. Comorbid diseases were identified in all patients: chronic pancreatitis and thrombus at the portal vein, penetrating duodenal ulcer, distal common bile duct stenosis, and diabetes mellitus. Diagnoses were performed by laparoscopic biopsy in two patients and via EUS fine needle aspiration in one patient. One patient revealed a multifocal microabscess at the pancreatic head caused by a deep-penetrating duodenal ulcer. He was treated with antibiotics and a proton-pump inhibitor. The clinical symptoms and pancreatic images of all the patients were improved using conservative management. Infective causes should be considered for a pancreatic mass mimicking malignancy.

Keywords: Pancreas, Abscess, Neoplasms, Endosonography

References

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Fig. 1.
Image studies of Case 1. (A) Axial view of the abdominal CT scan. A 2.7-cm ill-defined low-density mass (arrow) with peripancreatic fat infiltration was located at the pancreatic body. (B) Coronal view of the abdominal CT scan. An ill-defined, soft tissue density lesion around the celiac axis, common hepatic artery, splenic artery, and portal vein was noted (arrow). (C) PET-CT scan. Hot uptake (SUV 3.8) at the pancreatic body, indicating possible malignancy, was observed (arrow).
kjg-65-252f1.tif
Fig. 2.
Image studies of Case 2. (A) Axial view of the abdominal CT scan. A 5.0-cm well-defined low-density mass with heterogenous enhancement at the pancreas head (arrow), parenchymal atrophy, and a calcifying stone in the dilated pancreatic duct (arrowhead). (B) Coronal view of the abdominal CT scan. The portal vein and common hepatic artery were encased by a low-density mass (arrow). (C) Axial view of the abdominal CT scan after treatment. Resolution of the abscess was noted (arrowhead).
kjg-65-252f2.tif
Fig. 3.
Image studies of Case 3. (A, B) Axial and coronal views of the abdominal CT scan. A 1.2-cm well-defined low-density mass at the pancreatic head was observed (arrows). (C) Endoscopic ultrasonography. A 1.2-cm-sized anechoic round mass was seen at the pancreas head (arrows).
kjg-65-252f3.tif
Fig. 4.
Image studies of Case 4. (A) Axial view of the abdominal CT scan. A 1.7-cm multifocal ill-defined low-density lesion with multiple enhancing tubular structures at the head of the pancreas was observed (arrow). (B) PET-CT scan. Hot uptake (SUVmax 3.8) at the pancreatic head indicated possible malignancy or inflammation (arrow). (C, D) Endoscopic ultrasonography. A 2.8×1.6 cm-sized round isoechoic lesion with internal anechoic tubular structures was observed using vascular doppler (arrows). (E) Endoscopic finding. A 3.0-cm round deep-penetrating duodenal ulcer with a central pit was observed (arrow). (F) Endoscopic finding one year later. The duodenal ulcer had improved; however, the duodenal fistula remained (arrow).
kjg-65-252f4.tif
Table 1.
Baseline and Clinical Characteristics of the Four Patients
Case Sex/age (yr) Pancreas location Size (cm) Comorbidities Clinical symptoms WBC (mm3) CRP (mg/dL) CA 19-9(IU/ML) Diagnostic methods Patholgy/cytology Treatment
Case 1 F/51 Body 2.7 DM Abdominal pain 9,100 0.94 Normal Laparoscopy Stromal fibrosis, reactive lymph node hyperplasia Antibiotics
Case 2 F/65 Head 5.0 DM, CP Abdominal pain, fever 14,200 24.44 Normal Laparoscopy Acute and chronic inflammation Antibiotics
Case 3 M/77 Head 1.2 DM, HTN CBD stenosis Epigastric/ back pain 10,610 6.98 121.51 EUS-FNA Pus Antibiotics
Case 4 M/61 Head 2.8 DU Abdominal pain, weight loss 8,900 2.22 Normal EUS Not performed Antibiotics, PPIs

WBC, white blood cells; DM, diabetes mellitus; CP, chronic pancreatitis; HTN, hypertension; CBD, common bile duct; DU, duodenal ulcer; FNA, fine needle aspiration; PPI, proton pump inhibitors.

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