Case Of the Month

Pancreatic Necrosis vs. Pancreatic Neoplasia

Ultrasound, Pancreas, & Needles. Pancreatic necrosis vs. pancreatic neoplasia? That is the question for Jessie the geriatric Labrador retriever.
Imaging, US-guided FNA & Biopsy by Eric Lindquist DMV, DABVP and case management by Dr. Messina & staff at Madison AH, Madison, New Jersey, USA.

Sonogram (pancreas): Jessie

History (Vasquez RVT): A 10-year-old SF Labrador was presented for acute onset of vomiting, anorexia, and lethargy of approximately two days. The physical exam revealed a tense right cranial abdomen and tacky mucous membranes. Initial blood work had shown elevated ALP activity, amylase, lipase, BUN, and cholesterol and hypokalemia. Blood work performed two days later showed an improvement in the amylase and lipase and normal CBC.

Outcome

(Messina DVM, Madison AH Madison, NJ): The patient responded well to hospitalization and aggressive treatment for pancreatitis with pain management, plasma expansion, antibiotics and GI protectants. The patient was clinically normal at a 1-week follow-up. The amylase and lipase values normalized at a 14-day follow-up and the patient was clinically normal. 11 weeks later the patient presented with weakness and clinical signs consistent with pancreatitis/sepsis with elevated bilirubin values. The owners elected humane euthanasia at that point owing to poor quality of life from orthopedic and suspected recurrent pancreatic disease.

Comments

The elevated bilirubin in light of the position of the sampled pancreatic necrosis residing in the right pancreatic base would lead to the potential of post-hepatic obstruction as this patient’s potential final issue. This post-hepatic obstruction could not be confirmed through a recheck sonogram or post mortem examination. Technically, emerging neoplasia could have been present and not reflected in the fna or biopsy samples. But this was not suspected given the patient’s strong clinical response and the fact that multiple regions of the pancreatic sonographic heterogeneity were sampled in both cases in order to ensure adequate areas of the pathology were reflected in the samples.

Clinical Differential Diagnosis

(Remo Lobetti PhD, DECVIM):

Pancreas – pancreatitis, pancreatic neoplasia
GI tract – obstruction, neoplasia, intestinal perforation, infectious (viral, bacterial)

Sampling

(Lindquist DVM DABVP): Cytology of fine-needle aspirates were performed and revealed active hemorrhagic pancreatitis. Biopsy of the pancreas revealed moderate, acute, suppurative, necrotizing pancreatitis.

Sonographic Differential Diagnosis

(Lindquist DMV, DABVP): Pancreatitis with probable necrosis and sequestered tissue. Chronic active inflammation is likely given the mixed echogenicity of the tissue with irregular hyperechoic intrapancreatic changes suggestive for fibrosis and potential mineralization. Pancreatic neoplasia such as carcinoma cannot be ruled out and potentially suspected given signs of early mineralization (hyperechoic foci). The position of the pathology in the right limb and approaching the pancreatic base would predispose the patient to extra-hepatic common bile duct obstruction should bilirubin values begin to elevate.