Pathomorphological Features and Diagnostic Imaging

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A clear understanding of the characteristic features of GP, including documentation of the size and location of the mass, may be necessary when diagnostic imaging tests are employed. Imaging of the pancreas, common bile duct and duodenum by extra-abdominal ultrasound (US), endoscopic ultrasound (EUS), computed tomography (CT) and magnetic resonance imaging (MRI) of

Fig. 5. Marked thickening of the duodenal wall (endoscopy).

the abdomen may help to distinguish between GP scarring and neoplastic proliferation. The benign narrowing of the common bile duct in GP may be confirmed by endoscopic retrograde cholangiopancreatography (ERCP).

Pancreas

The mass located on the upper surface of the pancreas is whitish yellow with an elastic hard surface. Morphologically, various features such as fibrous scarring of the groove area and pericholedochal fibrosisis with inflammatory infiltrates are commonly seen. The Santorini duct is dilated and contains protein plugs.

The fibrous lesion is clearly imaged by US as a hypoechoic mass [4]. CT [5] reveals swelling of the pancreatic head and a heterogeneously enhanced low-density lesion in the groove. A sheet-like or plate-like mass is hypointense relative to the pancreatic parenchyma on T1-weighted images and iso- to slightly hyperintense on T2-weighted images [6]. The main pancreatic duct is not narrowed in pure GP, but narrowed in segmental GP. MR cholangiopancre-atography (MRCP) and endoscopic retrograde pancreatography (ERP) can also provide useful information.

Common Bile Duct

The biliary stricture is produced by fibrous scarring and chronic inflammation around the distal common bile duct. Because of scarring of the groove and thickening of the duodenum, the common bile duct bends to the left. An ultrasound endoscopy shows a dilated duct in the pancreatic head. ERCP shows that a stricture of the intra-pancreatic common bile duct is smooth, symmetrical and tapering, and that a stricture of the main pancreatic duct is occasionally irregular and incomplete. MRCP, like ERCP, shows stricture of the intrapancre-atic common bile duct.

Duodenum

The duodenum shows marked thickening of the wall due to fibrous scarring and hyperplasia of Brunner's gland. Microscopic foci of heterotopic pancreas with mild fibrosis are rarely seen in the wall of the minor papilla. Endoscopy demonstrates inflamed mucosa with a humped shape and a narrowed lumen of the duodenum. Hypotonic duodenography demonstrates the segmental narrowing of the supra-ampullary area and/or the upper portion of the C loop of the duodenum. T1-weighted images on dynamic study show the medial wall thickening of the descending duodenum, several small cysts in the groove and thickened duodenal wall.

Table 1. Distinct morphologic features of pancreatic carcinoma and groove pancreatitis (proposed by Mohl et al., 2001)

Pancreatic carcinoma Groove pancreatitis

Table 1. Distinct morphologic features of pancreatic carcinoma and groove pancreatitis (proposed by Mohl et al., 2001)

Pancreatic carcinoma Groove pancreatitis

Transabdominal

Enlarged mass, mostly in the pancreatic head,

'Groove' shown as hypoechoic zone between

ultrasound and

sometimes infiltration of the

pancreatic head and duodenum, thickening

endoscopic

duodenum and/or vessels; often

of the duodenal wall; at most minimal dilatation

ultrasound;

dilatation of the major pancreatic duct

of the common bile duct

abdominal CT

and/or the common bile duct

MRI

As in CT, frequently encasement of

'Sheet-like mass' in the groove, cysts, duodenal

vessels detectable.

wall thickening. No encasement of vessels.

Cholangiopancreatography studies: as

Cholangiopancreaticography studies: long

in ERCP (see below)

and smooth common bile duct stenosis or

medial shift of the duct

Endoscopy

Sometimes compression of the

Often duodenal stenosis caused by a thickened

duodenum or tumorous infiltration of the

wall, histopathologic any hyperplasia of Brunner's

duodenal wall

glands

ERCP

lrregular stenosis of the major pancreatic

Often tubular common bile duct stenosis, usually

duct, frequently accompanied by distal

intact pancreatic duct, sometimes stenosis and/or

common bile duct stenosis ('double duct sign')

dislocation of the pancreatic duct

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