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Fig. 1. A rounded low-attenuation mass in the pancreatic head suggests a neoplasm. |
Fig. 2.The absence of biliary ductal dilatation (not shown) and two focal calcifications favor chronic pancreatitis. |
Fig. 3. CT-guided percutaneous biopsy of the pancreatic head mass was performed using a 19-gauge guiding needle. The CT gantry was tilted to avoid transgressing the colon. |
Fig. 4. Follow-up CT scan shows pancreatic head enlargement and stranding suggesting post-biopsy pancreatitis. |
Case Reference No. CC-797-02 A 51-year-old man underwent CT imaging for evaluation of abdominal pain. A mass in the pancreatic head was identified (Figs. 1, 2). Percutaneous biopsy was performed (Fig. 3). Aspiration biopsy through a guiding needle was performed twice with a 20-gauge needle. The resulting sample had insufficient cellular material for diagnosis, so two 20-gauge cores were obtained. These were interpreted as being consistent with chronic pancreatitis. |
Fig. 5. Thrombus is now identified within the portal vein (arrow). |
One day after the biopsy, the abdominal pain worsened and CT evaluation was repeated, demonstrating changes of acute pancreatitis and portal vein thrombosis (Figs. 4, 5). Serum amylase and lipase were now elevated. The pancreatitis was managed medically. After discussing thrombolytic options, we decided upon a 3-month course of anticoagulation to prevent propagation of portal venous thrombosis. His symptoms resolved within 2 days. At 3-month follow-up, he was completely asymptomatic. |
Questions: 1) How closely should patients be followed for pancreatitis after pancreatic biopsy? Is this complication more likely when performing a biopsy of non-neoplastic abnormalities? 2) If there were no other access routes, would you perform percutaneous transcolonic pancreatic biopsy? How large a needle would you use? 3) Is there any role for portal venous thrombolysis in this setting? If so, would you obtain percutaneous transhepatic access or transjugular access? Would you consider transcatheter SMA infusion? Related cases: |
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