EURORAD ESR

Case 13694

Disconnected pancreatic duct syndrome: imaging findings and endoscopic treatment

Author(s)
Tonolini Massimo, M.D.1; Vella Adriana, M.D.1; Bareggi Emilia, M.D.2; Gambitta Pietro, M.D.2

"Luigi Sacco" University Hospital,
(1) Radiology Department
(2) Gastroenterology Department
Via G.B. Grassi 74
20157 Milan, Italy;
Email:mtonolini@sirm.org
 
Patient
male, 56 year(s)
 
 
  • Figure 1
    Initial unenhanced CT study upon arrival at our institution
     

    Cysto-gastrostomy with metallic stent (thin arrows) and nasal-cystic tube (arrows) was previously positioned to drain the major peripancreatic collection (*).

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Abscess delineation; Special Focus: Acute;

    Cysto-gastrostomy with metallic stent (thin arrows) and nasal-cystic tube (arrows) was previously positioned to drain the major peripancreatic collection (*).

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Abscess delineation; Special Focus: Acute;

    Maximum-intensity projection (MIP) images showed the metallic stent (thin arrows) and nasal-cystic tube (arrows) previously positioned at the cysto-gastrostomy.

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Abscess delineation; Special Focus: Acute;
     
     
  • Figure 2
    Initial endoscopic treatment
     

    Pancreatic necrosectomy was performed through the cysto-gastrostomy with nasal-cystic tube (arrows).

     
    Area of Interest: Pancreas; Imaging Technique: Fluoroscopy; Procedure: Catheters; Special Focus: Acute;

    The nasal-cystic tube was then removed and replaced with a pigtail stent (arrow) positioned through the metallic stent already in place.

     
    Area of Interest: Pancreas; Imaging Technique: Fluoroscopy; Procedure: Catheters; Special Focus: Acute;

    After clinical improvement, both stents were endoscopically removed.

     
    Area of Interest: Pancreas; Imaging Technique: Fluoroscopy; Procedure: Catheters; Special Focus: Acute;
     
     
  • Figure 3
    Unenhanced and post-contrast CT after premedication
     

    Unenhanced (a) and post-contrast (b,c) images showed reappearance of the major post-necrotic fluid collection (*) measuring approximately 9x2.5 cm, located above the pancreatic body-tail (+).

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Acute;

    Unenhanced (a) and post-contrast (b,c) images showed reappearance of the major post-necrotic fluid collection (*) measuring approximately 9x2.5 cm, located above the pancreatic body-tail (+).

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Acute;

    Unenhanced (a) and post-contrast (b,c) images showed reappearance of the major post-necrotic fluid collection (*) measuring approximately 9x2.5 cm, located above the pancreatic body-tail (+).

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Acute;

    The pancreatic body and tail (+) were recognizable with preserved anatomic continuity and enhancement. The main pancreatic duct was not perceptible. Note major post-necrotic fluid collection (*).

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Acute;

    The pancreatic body and tail (+) were recognizable with preserved anatomic continuity and enhancement. The main pancreatic duct was not perceptible.

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Acute;
     
     
  • Figure 4
    Unenhanced MRI with MR-cholangiopancreatography (MRCP)
     

    Axial T1-(a), T2-(b), diffusion-weighted (c) and apparent diffusion coefficient (ADC) map (d) showed stable major post-necrotic fluid collection (*) measuring approximately 9x2.5 cm, located above the pancreatic...

     
    Area of Interest: Pancreas; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Acute;

    Axial T1-(a), T2-(b), diffusion-weighted (c) and apparent diffusion coefficient (ADC) map (d) showed stable major post-necrotic fluid collection (*) measuring approximately 9x2.5 cm, located above the pancreatic...

     
    Area of Interest: Pancreas; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Acute;

    Axial T1-(a), T2-(b), diffusion-weighted (c) and apparent diffusion coefficient (ADC) map (d) showed stable major post-necrotic fluid collection (*) measuring approximately 9x2.5 cm, located above the pancreatic...

     
    Area of Interest: Pancreas; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Acute;

    Axial T1-(a), T2-(b), diffusion-weighted (c) and apparent diffusion coefficient (ADC) map (d) showed stable major post-necrotic fluid collection (*) measuring approximately 9x2.5 cm, located above the pancreatic...

     
    Area of Interest: Pancreas; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Acute;

    Axial T1- (e) and T2-(f) weighted images confirmed pancreatic body and tail (+) with preserved anatomic continuity and thickness within normal range.

     
    Area of Interest: Pancreas; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Acute;

    Axial T1- (e) and T2-(f) weighted images confirmed pancreatic body and tail (+) with preserved anatomic continuity and thickness within normal range.

     
    Area of Interest: Pancreas; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Acute;

    The cysto-gastrostomy (arrowhead) was stille recognizable.

     
    Area of Interest: Pancreas; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Acute;

    MRCP showed mild dilatation of the Wirsung duct at the pancreatic head (arrow), and segmental discontinuity (thick arrow) of the main pancreatic duct in the body. Normal appearance of the biliary tract.

     
    Area of Interest: Pancreas; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Acute;

    MRCP showed mild dilatation of the Wirsung duct at the pancreatic head (arrow), and segmental discontinuity (thick arrow) of the main pancreatic duct in the body. Normal appearance of the biliary tract.

     
    Area of Interest: Pancreas; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Acute;
     
     
  • Figure 5
    Definitive endoscopic treatment
     

    Repeated ERCP confirmed MRCP findings of mild dilatation of the Wirsung duct in the pancreatic head (arrow), and focal discontinuity (thick arrow) of the main pancreatic duct in the body.

     
    Area of Interest: Pancreas; Imaging Technique: Fluoroscopy; Procedure: Catheters; Special Focus: Acute;

    Definitive endoscopic treatment required positioning of a long pancreatic stent (arrowhead) through the main pancreatic duct discontinuity. Note mild dilatation of the Wirsung duct in the pancreatic head (arrow),

     
    Area of Interest: Pancreas; Imaging Technique: Fluoroscopy; Procedure: Catheters; Special Focus: Acute;
     
     
Cysto-gastrostomy with metallic stent (thin arrows) and nasal-cystic tube (arrows) was previously positioned to drain the major peripancreatic collection (*).
 
Cysto-gastrostomy with metallic stent (thin arrows) and nasal-cystic tube (arrows) was previously positioned to drain the major peripancreatic collection (*).
 
Maximum-intensity projection (MIP) images showed the metallic stent (thin arrows) and nasal-cystic tube (arrows) previously positioned at the cysto-gastrostomy.
 
Pancreatic necrosectomy was performed through the cysto-gastrostomy with nasal-cystic tube (arrows).
 
The nasal-cystic tube was then removed and replaced with a pigtail stent (arrow) positioned through the metallic stent already in place.
 
After clinical improvement, both stents were endoscopically removed.
 
Unenhanced (a) and post-contrast (b,c) images showed reappearance of the major post-necrotic fluid collection (*) measuring approximately 9x2.5 cm, located above the pancreatic body-tail (+).
 
Unenhanced (a) and post-contrast (b,c) images showed reappearance of the major post-necrotic fluid collection (*) measuring approximately 9x2.5 cm, located above the pancreatic body-tail (+).
 
Unenhanced (a) and post-contrast (b,c) images showed reappearance of the major post-necrotic fluid collection (*) measuring approximately 9x2.5 cm, located above the pancreatic body-tail (+).
 
The pancreatic body and tail (+) were recognizable with preserved anatomic continuity and enhancement. The main pancreatic duct was not perceptible. Note major post-necrotic fluid collection (*).
 
The pancreatic body and tail (+) were recognizable with preserved anatomic continuity and enhancement. The main pancreatic duct was not perceptible.
 
Axial T1-(a), T2-(b), diffusion-weighted (c) and apparent diffusion coefficient (ADC) map (d) showed stable major post-necrotic fluid collection (*) measuring approximately 9x2.5 cm, located above the pancreatic body-tail.
 
Axial T1-(a), T2-(b), diffusion-weighted (c) and apparent diffusion coefficient (ADC) map (d) showed stable major post-necrotic fluid collection (*) measuring approximately 9x2.5 cm, located above the pancreatic body-tail.
 
Axial T1-(a), T2-(b), diffusion-weighted (c) and apparent diffusion coefficient (ADC) map (d) showed stable major post-necrotic fluid collection (*) measuring approximately 9x2.5 cm, located above the pancreatic body-tail.
 
Axial T1-(a), T2-(b), diffusion-weighted (c) and apparent diffusion coefficient (ADC) map (d) showed stable major post-necrotic fluid collection (*) measuring approximately 9x2.5 cm, located above the pancreatic body-tail.
 
Axial T1- (e) and T2-(f) weighted images confirmed pancreatic body and tail (+) with preserved anatomic continuity and thickness within normal range.
 
Axial T1- (e) and T2-(f) weighted images confirmed pancreatic body and tail (+) with preserved anatomic continuity and thickness within normal range.
 
The cysto-gastrostomy (arrowhead) was stille recognizable.
 
MRCP showed mild dilatation of the Wirsung duct at the pancreatic head (arrow), and segmental discontinuity (thick arrow) of the main pancreatic duct in the body. Normal appearance of the biliary tract.
 
MRCP showed mild dilatation of the Wirsung duct at the pancreatic head (arrow), and segmental discontinuity (thick arrow) of the main pancreatic duct in the body. Normal appearance of the biliary tract.
 
Repeated ERCP confirmed MRCP findings of mild dilatation of the Wirsung duct in the pancreatic head (arrow), and focal discontinuity (thick arrow) of the main pancreatic duct in the body.
 
Definitive endoscopic treatment required positioning of a long pancreatic stent (arrowhead) through the main pancreatic duct discontinuity. Note mild dilatation of the Wirsung duct in the pancreatic head (arrow),
 
 
 
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