A Case of Intraabdominal Tuberculosis with Pancreatic Involvement Showing Interesting ERP Finding

Kang, Jin Kyung; Park, In Suh; Chung, Jae Bock; Song, Si Young; Park, Chan Il; Park, Seung Woo; Park, Jae Min; Lee, Woo Jung; Choi, Yoon Chung

Abstract

Tuberculosis of the pancreas is a very rare disorder, little reported in the literature. Several theories of the pathogenesis of pancreatic tuberculosis have been proposed. Direct invasion of the pancreas by Mycobacterium tuberculosis is rare; most commonly the pancreas is spared even when liver and spleen are severely involved by miliary dissemination. More common is the involvement of abdominal lymph nodes which, as caseating masses, subsequently invade the pancreas. Pancreatic tuberculosis is a treatable and preventable disease; however, major challenges remain in diagnosis. There have been several reports including the endoscopic retrograde pancreatographic(ERP) findings, however, our case of pancreatic tuberculosis showed quite unusual ERP findings. We report a 54-year old man suffering from chronic epigastric pain and weight loss who was diagnosed intraabdominal tuberculosis with pancreatic involvement. Abdominal ultrasonography showed ill-defined hypoechoic mass at pancreatic head, peripancreatic lymph nodes enlargement and intra- and extrahepatic bile ducts dilatations. Endoscopic retrograde pancreatogram showed blurring and irregularity of the second branch of pancreatic duct at head and the parenchymal abnormal pooling of the contrast dye was noted. Percutanieous transhepatic cholangiogram revealed the complete obstruction of the distal common bile duct. At explo-laparotomy, massive necrosis and fibrous adhesions were noticed around the extrahepatic bile duct and pancreas head and multiple pericholedochal lymph nodes enlargement and several whitish-yellow nodules on the surface of the liver were noted. The extrahepatic bile duct was dilated and the common bile duct at the suprapancreatic portion was compressed by the lymph nodes and necro-inflammatory tissues which invaded the pancreatic head posteriorly. The microscopic findings of the nodules on liver surface and lymph nodes revealed the typical findings of the tuberculosis.