Acute hemorrhagic cholecystitis and pancreatitis secondary to a metastasis to the pancreas

Case contributed by Dr Cedric Bohyn

Presentation

Patient with known metastatic lung carcinoma presenting with upper abdominal pain, nausea, and vomiting.

Patient Data

Age: 60 years
Gender: Female

Long segment stenosis of the distal common bile duct and pancreatic duct with dilatation of the bile duct system and mild dilatation of the pancreatic duct.

Severe cholecystitis complicated by hemorrhage seen as T1 hyperintense luminal content (hemorrhagic cholecystitis). 

Edemateous swelling of the pancreas with diffuse diffusion restriction (average ADC-value of 828 x 10-3 mm2/s) consistent with acute interstitial edematous pancreatitis. 

Diffuse metastatic lymphadenopathy in the gastrohepatic ligament, mesentery, retroperitoneal space, and liver hilum.

Bilateral pleural effusion and presence of free intraperitoneal fluid.

Bilateral adrenal adenoms.

Lab results at the time of presentation showed increased lipase blood levels (220 U/L).

The patient went on to have an endoscopic ultrasound scan (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) revealing malignant stenosis of the distal common bile duct. The endoscopic ultrasound-guided fine-needle aspiration biopsy confirmed metastatic lung carcinoma.

Case Discussion

This is a case of acute pancreatitis and hemorrhagic cholecystitis as a result of obstruction from a metastasis.

This case illustrates typical findings of acute pancreatitis with the parenchyma appearing mildly hypointense on T1-weighted, mildly hyperintense on heavily T2-weighted images, and positive diffusion restriction. This case nicely demonstrates the usefulness of diffusion-weighted imaging as the restriction diffusion is easy to spot and confirms the suspected diagnosis of acute edematous pancreatitis.

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