Imaging Pearls ❯ Pancreas ❯ Pancreatic Pseudolesion
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- The radiologic finding of focal stenosis of the main pancreatic duct is highly suggestive of pancreatic cancer. Even in the absence of a mass lesion, focal duct stenosis can lead to surgical resection of the affected portion of the pancreas. We present four patients with distinctive pathology associated with non-neoplastic focal stenosis of the main pancreatic duct. The pathology included stenosis of the pancreatic duct accompanied by wavy, acellular, serpentine-like fibrosis, chronic inflammation with foreign body–type giant cell reaction, and calcifications. In all cases, the pancreas toward the tail of the gland had obstructive changes including acinar drop-out and interlobular and intralobular fibrosis. Three of the four patients had a remote history of major motor vehicle accidents associated with severe abdominal trauma. These results emphasize that blunt trauma can injure the pancreas and that this injury can result in long term complications, including focal stenosis of the main pancreatic duct. Pathologists should be aware of the distinct pathology associated with remote trauma and, when the pathology is present, should elicit the appropriate clinical history.
Distinctive Pathology Associated With Focal Stenosis of the Main Pancreatic Duct Secondary to Remote Trauma: A Long-term Complication of Seat Belt Pancreatitis.
Wu AA, Thompson ED, Cameron JL, He J, Burkhart RA, Burns WR, Lafaro KJ, Shubert CR, Canto MI, Fishman EK, Hruban RH.
Am J Surg Pathol. 2024 Mar 14. doi: 10.1097/PAS.0000000000002207. Epub ahead of print. PMID: 38482693. - “Four cases of non-neoplastic cutoff of the main pancreatic duct with distinctive pathology are presented. The pathology included abrupt duct stenosis, changes suggestive of rupture of the pancreatic duct, wavy, acellular, serpentine-like stromal fibrosis, and a foreign body– type giant cell reaction. IgG4 immunohistochemical stain was below the threshold in all cases, ruling out a type 1 autoimmune pancreatitis, and no neoplasms were present. Three of the four patients had a history of major motor vehicle accidents with associated severe abdominal trauma, suggesting that the unique pathology was caused by the trauma.”
Distinctive Pathology Associated With Focal Stenosis of the Main Pancreatic Duct Secondary to Remote Trauma : A Long-term Complication of Seat Belt Pancreatitis
Annie A. Wu, MD, PhD,* Elizabeth D. Thompson, MD, PhD,*† John L. Cameron, MD,‡ Jin He, MD, PhD,‡ Richard A. Burkhart, MD,‡ William R. Burns, MD,‡ Kelly J. Lafaro, MD, MPH,‡ Christopher R. Shubert, MD, MHA,‡ Marcia I. Canto, MD, MHS,†§ Elliot K. Fishman, MD,∥ and Ralph H. Hruban, MD*†
Am J Surg Pathol 2024;00:000–000) (in press) 
- “The presence of biliary stents (both plastic and metal) may hamper CT assessment because they cause artifacts and post-ERCP inflammatory changes on CT images.”
Diagnostic value of a pancreatic mass on computed tomography in patients undergoing pancreatoduodenectomy for presumed pancreatic cancer. Gerritsen A et al. Surgery. 2015 Jul;158(1):173-82 - “Nonetheless, in clinical practice it is preferred to perform CT imaging before placement of a biliary stent in patients with suspected pancreatic cancer.”
Diagnostic value of a pancreatic mass on computed tomography in patients undergoing pancreatoduodenectomy for presumed pancreatic cancer. Gerritsen A et al. Surgery. 2015 Jul;158(1):173-82
- “ Pancreatic fat can be quantified by using CT, and CT attenuation indexes that are applied to the quantification of pancreatic fat are significantly associated with clinical assessment of impaired glucose metabolism.”
Quantitative Assessment of Pancreatic Fat by Using Unenhanced CT: Pathologic Correlation and Clinical Implications
Kim SY et al.
Radiology 2014; 271:104-112 - “ CT attenuation indexes that are applied to the quantification of pancreatic fat are significantly associated with clinical assessment of impaired glucose metabolism.”
Quantitative Assessment of Pancreatic Fat by Using Unenhanced CT: Pathologic Correlation and Clinical Implications
Kim SY et al.
Radiology 2014; 271:104-112
- “This case illustrates the ability of EUS to distinguish pancreatic from nonpancreatic processes that may not be appreciated on contrast-enhanced CT.”
Nearly missed GI stromal tumor: EUS diagnosis of a jejunal GI stromal tumor mistaken for a pancreatic mass on CT
Kularatna G et al.
Gastrointest Endosc 2010 May;71(6):1065-66
- “ Congenital anomalies and normal variants of the pancreas can present a diagnostic challenge when encountered. Knowledge of pancreatic embryology and of normal anatomic variants is essential to identify these entities and help differentiate them from pathologic conditions, thus preventing potential unnecessary imaging investigation or more invasive procedures such as biopsy of surgery.”
Anomalies, Anatomic Variants, and Sources of Diagnostic Pitfalls in Pancreatic Imaging
Borghei P et al.
Radiology 2013,266:28-36 - Congenital Anomalies of the Pancreas
- Pancreas divisum
- Annular pancreas
- Variation in pancreatic duct course
- Agenesis and hypoplasia of the pancreas
- Ectopic pancreas
- Pancreatic cysts - Normal Variants and Pitfalls of the Pancreas
- Fatty infiltration
- Pseudomass
- Anomalies, Anatomic Variants, and Sources of Diagnostic Pitfalls in Pancreatic Imaging
Borghei P et al.
Radiology 2013,266:28-36 - Normal Variants and Pitfalls of the Pancreas
1. Fatty infiltration
2. Pseudomass
- Lobulations of the pancreatic head
- Nodes near the pancreas simulate a pancreatic mass
- Splenules simulating a tail of pancreas mass
- Focal autoimmune pancreatitis - Annular Pancreas: Facts
- Segment of pancreas surrounds the second portion of the duodenum
- Annular pancreas can be confused with a pancreatic mass
- Two types: extramural and intramural
- Extramural presents with duodenal obstruction while intramural presents with duodenal ulcerations
- Pancreatic Pseudolesions: Tail of Pancreas
- Left adrenal lesion
- small bowel tumor
- Accessory spleen or splenules
- Gastric GIST tumors
- Retroperitoneal sarcomas
- Lymphangiomas or lymphoepithelial cyst - Pancreatic Pseudolesions: Body of Pancreas
- Gastric tumors (posterior gastric wall)
- Duodenal tumors
- Pseudocysts - Pancreatic Pseudolesions: Head and Neck of Pancreas
- Unenhanced/unopacified duodenum
- Duodenal diverticulum
- Duodenal or Gastric GIST tumor
- Adenopathy
- Common bile duct lesions including choledochal cysts
- Annular pancreas - Pancreatic Pseudolesions: Differential Diagnosis
- Head and neck of pancreas
- Body of the pancreas
- Tail of the pancreas
- Fact: each zone has some unique poential pitfalls