ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Grace Elta and Robert J. Fontana, Section Editors
Got Milk? An Unusual Cause of Abdominal Pain Edward L. Barnes and Linda S. Lee Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women’s Hospital, Boston, Massachusetts
Question: A 43-yearold woman with a history of abdominal trauma from a motor vehicle accident 3 years before admission presented with increasing severe abdominal pain located in the epigastrium and left upper quadrant with radiation to the back, significant nausea, and intermittent vomiting. The pain was exacerbated by both eating and drinking. On physical examination, she was afebrile with a soft abdomen that was tender to minimal palpation in the epigastric and left upper quadrant regions. Laboratory data were notable for normal amylase, lipase, liver function tests, white blood cell count, and hematocrit. The pain improved minimally with NPO status and intravenous fluids. Initial MRI of the pancreas before admission demonstrated pancreatitis involving the neck and body of the pancreas with peripancreatic fluid. A follow-up MRI was performed (Figure A, B). Endoscopic ultrasound confirmed subsequently the presence of multiloculated cysts adjacent to the neck–body of the pancreas with the largest pocket measuring 2.5 1.6 cm and normal-appearing adjacent pancreatic parenchyma and pancreatic duct (Figure C). Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) yielded this fluid (Figure D). What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Conflicts of interest The authors disclose no conflicts. © 2015 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2014.09.035
Gastroenterology 2015;148:e1–e2
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Answer to the Clinical Challenges and Images in GI Question: Image 1: Pancreatic Lymphangioma
EUS-FNA revealed milky fluid with carcinoembryonic antigen 1.8 ng/mL, amylase 307 U/L, lipase 382 U/L, and triglyceride 2,972 mg/dL. During subtotal pancreatectomy, a cystic mass was identified involving the pancreatic body on the left with a normal tail to the right in the image (Figure E). Heavy cream delivered via a nasogastric tube in the duodenum produced milky fluid seen leaking from lymphatics and the cyst cavity. Most commonly presenting in children, lymphangiomas are rare, benign neoplasms that arise from obstructed lymphatic vessels, which progressively dilate cystically owing to detachment of lymphatic tissue during embryologic development.1 First described by Koch in 1913, pancreatic lymphangiomas are exceedingly rare, representing
Got Milk? An Unusual Cause of Abdominal Pain Edward L. Barnes and Linda S. Lee Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women’s Hospital, Boston, Massachusetts
Question: A 43-yearold woman with a history of abdominal trauma from a motor vehicle accident 3 years before admission presented with increasing severe abdominal pain located in the epigastrium and left upper quadrant with radiation to the back, significant nausea, and intermittent vomiting. The pain was exacerbated by both eating and drinking. On physical examination, she was afebrile with a soft abdomen that was tender to minimal palpation in the epigastric and left upper quadrant regions. Laboratory data were notable for normal amylase, lipase, liver function tests, white blood cell count, and hematocrit. The pain improved minimally with NPO status and intravenous fluids. Initial MRI of the pancreas before admission demonstrated pancreatitis involving the neck and body of the pancreas with peripancreatic fluid. A follow-up MRI was performed (Figure A, B). Endoscopic ultrasound confirmed subsequently the presence of multiloculated cysts adjacent to the neck–body of the pancreas with the largest pocket measuring 2.5 1.6 cm and normal-appearing adjacent pancreatic parenchyma and pancreatic duct (Figure C). Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) yielded this fluid (Figure D). What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Conflicts of interest The authors disclose no conflicts. © 2015 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2014.09.035
Gastroenterology 2015;148:e1–e2
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Answer to the Clinical Challenges and Images in GI Question: Image 1: Pancreatic Lymphangioma
EUS-FNA revealed milky fluid with carcinoembryonic antigen 1.8 ng/mL, amylase 307 U/L, lipase 382 U/L, and triglyceride 2,972 mg/dL. During subtotal pancreatectomy, a cystic mass was identified involving the pancreatic body on the left with a normal tail to the right in the image (Figure E). Heavy cream delivered via a nasogastric tube in the duodenum produced milky fluid seen leaking from lymphatics and the cyst cavity. Most commonly presenting in children, lymphangiomas are rare, benign neoplasms that arise from obstructed lymphatic vessels, which progressively dilate cystically owing to detachment of lymphatic tissue during embryologic development.1 First described by Koch in 1913, pancreatic lymphangiomas are exceedingly rare, representing
