Clin Endosc.  2019 Mar;52(2):196-200. 10.5946/ce.2018.097.

Endoscopic Ultrasound in the Diagnosis of Pancreatoduodenal Groove Pathology: Report of Three Cases and Brief Review of the Literature

• Oría IC
• Pizzala JE
• Villaverde AM
• Spina JC
• Pasqua AV
• Lazarte JC
• Mazza OM
• Marcolongo MM

• KMID: 2447679
• DOI: http://doi.org/10.5946/ce.2018.097

Abstract

The pancreatoduodenal groove is a small area where pathologic processes involving the distal bile duct, duodenum, pancreatic head, ampulla of Vater, and retroperitoneum converge. Despite great advances in imaging techniques, a definitive preoperative diagnosis is challenging because of the complex anatomy of this area. Therefore, surgical intervention is frequently required because of the inability to completely exclude malignancy. We report 3 cases of patients with different groove pathologies but similar clinical and imaging presentation, and show the essential role of endoscopic ultrasound (EUS) in making a specific preoperative diagnosis, excluding malignancy in the first case, changing diagnosis in the second case, and confirming malignancy in the third case. EUS was a fundamental tool in this cohort of patients, not only because of its ability to provide superior visualization of a difficult anatomical region, but because of the ability to guide precise, real-time procedures, such as fine-needle aspiration.

Keyword

Pancreatoduodenal groove; Endoscopic ultrasound; Fine needle aspiration; Pancreatic cancer; Groove pancreatitis

MeSH Terms

Ampulla of Vater
Bile Ducts
Biopsy, Fine-Needle
Cohort Studies
Diagnosis*
Duodenum
Head
Humans
Pancreatic Neoplasms
Pathologic Processes
Pathology*
Ultrasonography*

Figure

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  Fig. 1. (A-D) Magnetic resonance cholangiopancreatography. Cephalic pancreatic mass with poorly defined margins and heterogeneous fluid signal, without significant contrast enhancement. The distal bile duct is slightly deformed without compression. Non-dilated pancreatic duct. Thickening of the second part of duodenum. Cystic lesion at the pancreaticoduodenal groove.

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  Fig. 2. Endoscopic ultrasound with fine-needle aspiration. (A) Pancreatic body and tail: lobularity with honeycombing, hyperechoic foci without shadowing. (B) Pancreatic head: hypoechoic mass with irregular margins, hyperechoic foci and lobularity. (C) Semi-circumferential parietal thickening of the second part of the duodenum. (D) Intraparietal duodenal cyst. (E) Endoscopically, edematous mucosa with a polypoid hyperplastic appearance in the second part of the duodenum.

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  Fig. 3. (A, B) Multiple detector computed tomography, axial portal venous phase (A) and coronal portal venous phase (B), showing globular appearance of pancreatic head and uncinate process. Concentric duodenal wall thickening with a diverticular image appearance on the anterior wall associated with periduodenal fat stranding and an air bubble. Note also a fine fluid band. (C) Endoscopic ultrasound (EUS). Normal echogenicity of the pancreatic gland without focal lesions. At the level of first and second part of the duodenum, EUS revealed a semi-circumferentially-thickened duodenal wall with disruption of layer configuration. (D) Endoscopically, at the duodenal knee, a large ulcer occupying half of the duodenal circumference covered with fibrin was seen.

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  Fig. 4. (A, B) Computed tomography: Axial plane images showed a hypodense lesion in the groove area with paraduodenal cysts and a dilated biliary tree. (C) Endoscopic ultrasound (EUS). Pancreatic head: Hypoechoic mass with irregular margins, slightly dilated pancreatic duct. (D) EUS. Parietal thickening of the second part of the duodenum. Intraparietal duodenal cysts. (E, F) Pathological specimen: a pale and indurated lesion located in the pancreatic head with cyst formation on the duodenal wall.

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