A gastric polyp, prolapsing into the duodenum, can result in acute pancreatitis.
CASE HISTORY
A woman of 70 was referred after six months of recurrent pancreatitis with 12kg weight loss. She was otherwise well, was not on any regular medication and did not drink alcohol. Before transfer, a CT scan had been reported as showing a cystic mass in the head of the pancreas. Endoscopic retrograde cholangiopancreatography revealed a ‘mucosal bulge’ in the duodenum with normal delineation of the biliary tree. On repeat CT scanning the cystic mass was unchanged (Figure 1a). The pancreas was oedematous. When her pancreatitis recurred, with raised serum amylase, alkaline phosphatase, alanine aminotransferase, gammaglutamyl transferase and bilirubin, a further CT scan revealed, in addition to the cystic mass, dilatation of the extrahepatic and intrahepatic biliary ducts. Laparotomy was decided on with the aim of draining the cyst and performing a cholecystectomy. At operation the gallbladder was seen to be dilated, with a swelling behind the first part of the duodenum which promptly disappeared after decompression of the common bile duct. After routine cholecystectomy the common bile duct was explored with a choledochoscope. No stones were identified.
Figure 1.
Contrast enhanced abdominal CT scans. (a) White arrows show cystic lesion in the region of the pancreatic head. (b) Subsequent scan shows this lesion within stomach (black arrows)
Her recovery was uncomplicated until postoperative day 21 when the symptoms of pancreatitis recurred, with increases in serum amylase, alkaline phosphatase, alanine aminotransferase, and gamma glutamyl transferase but normal bilirubin. A CT scan now showed a thick walled. cystic lesion superior to the tail of the pancreas pushing into the lesser curvature of the stomach (Figure 1b). There was no cyst in the head of the pancreas. On gastroscopy a large mobile pedunculated polyp was seen in the fundus of the stomach, and a barium meal showed that the polyp was prolapsing into the duodenum (Figure 2). At repeat laparotomy the polyp, which was about 5 cm in diameter, was delivered and excised via a gastrotomy. It proved to be a benign cystic leiomyoma. Eighteen months later there had been no symptom recurrence and the lost weight had been regained.
Figure 2.
Double-contrast barium meal. Large polyp (arrows) arising from the gastric fundus (a) and prolapsing into the duodenum (b)
COMMENT
Exclusion of gallstones, alcohol and drug intake in a patient with acute pancreatitis often prompts a diagnosis of idiopathic pancreatitis. We have found only three reports1-3 on pancreatitis associated with a gastric polyp and none with repeated episodes as in the present case.
Gastroduodenal intussusception is most commonly due to a benign tumour,1 and Gardner's syndrome (familial adenomatous polyposis)2 is one condition in which it has caused pancreatititis.2
A cystic lesion in the vicinity of the pancreas on CT scan, in a patient with a history of acute pancreatitis, is usually interpreted as pseudocyst. In the patient reported here this misinterpretation led to a delay in diagnosis and definitive treatment.
References
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