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A 53-year-old man presents to the emergency department (ED) complaining of chronic intermittent mid-epigastric pain, which he says is progressively getting worse. There is no history of trauma or prior malignancy. Lab values reveal elevated liver function tests with no signs of infection. Basic urine chemistry is unremarkable with no hematuria. The patient denies excessive alcohol use but the wily, experienced ED doc takes that denial with a large grain of salt. On further questioning, he reports passing bulky, foul-smelling stools, which are difficult to flush, for more than 6 months. A non-contrast abdominal CT scan is ordered (Figure 1).
The most likely diagnosis from the history, presentation and CT scan image is:
a) ruptured atherosclerotic abdominal aortic aneurysm
b) calcified splenic varices from cirrhotic liver disease
c) incidental splenic artery aneurysm
d) multiple left kidney stones with hydronephrosis
e) chronic calcific pancreatitis
Michael K. McLennan, MD, FRCPC is a diagnostic radiologist at Markham Stouffville Hospital in Markham, ON, and at Uxbridge Cottage Hospital. He did his medical training and radiology residency at the University of Toronto, and has published over 600 medical imaging articles.
The most likely diagnosis is (e): chronic calcific pancreatitis
The transverse soft tissue structure shown in the computed tomography (CT) image, which has punctuate calcifications within, represents an atrophic pancreas that has changes in keeping with chronic pancreatitis with secondary calcific change. Figure 2 details the various regional anatomy. The bulky, foul-smelling, fatty stools (hard to flush) are a result of chronic pancreatic enzyme insufficiency from the underlying disorder.
Chronic calcific pancreatitis (CCP) is a special form of chronic pancreatitis that tends to calcify or is associated with pancreatic lithiasis. The calcifications are typically punctate in nature and either represent true stones in the pancreatic duct system (called pancreatic calculi) or dystrophic calcification of the gland parenchyma.
The most common cause of CCP is excessive alcohol intake. Diagnostic imaging plays a major role in assessing these patients: making the diagnosis, staging of the severity of disease, detection of complications and assistance in deciding on potential treatment options. Both CT and ultrasound can be of great benefit although anatomical visualization is typically far greater in the former (as overlying bowel gas can severely obscure visualization of deep structures with sonography). Magnetic resonance cholangiopancreatography (MRCP) in a non-invasive study and doesn’t utilize ionizing radiation. MRCP provides noninvasive biliary and pancreatic duct imaging and accurate characterization of pancreatic and peripancreatic pathology. The gold standard for assessing the pancreatic duct system remains endoscopic retrograde cholangiopancreatography (ERCP) but is reserved for late in the assessment stage, if at all, mainly due to the invasive nature of the study. Unlike ERCP, MRCP can show the dilated pancreatic duct upstream from an obstructing stone.
There are numerous surgical techniques that have been developed to assist patients with severe chronic pancreatitis; however, surgery is still considered a last resort and the majority of patients and their complications can be treated conservatively.
Of the other choices available, a ruptured atherosclerotic abdominal aortic aneurysm is out, since the aorta is normal in calibre and appearance (see Figure 2) and no free fluid/hemorrhage is evident. There are no varices present and in any case, they rarely calcify. The calcified structure in Figure 1 is too large and diffuse to represent a calcified splenic artery aneurysm. Neither kidney
is even represented on the image shown, so that option is nixed.
References:
- Sandrasegaran K et al. Am J Roentgenol 2005;184:1118-27.
- Miller FH et al. An J Roentgenol 2004; 183:1645-52.
- Manfredi R et al. Rays 2001;26(2):143-9.
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