groovepancreatitis Myoadenomatosis Cystic dystrophy of heterotopic pancreas Para-duodenal wall cyst Pancreatic hamartoma of duodenum Paraduodenal pancreatitis

1. “IN THE GROOVE”
A RARE CASE
PRESENTATION

2.  38 year old Male
 C/O abdominal pain – 2days
 Vomiting – 2days

3. Abdominal pain
 Mainly in the epigastric region
 Dull boring type of pain
 Continuous in nature
 Radiating to back
 Increased with food intake
 Relieved by leaning forward and analgesics

4. Vomiting
 Spontaneous
 Non projectile
 5-6 episodes per day
 Non bilious
 Non blood stained
 Contained recently ingested food particles

5.  No h/o jaundice/ pale stools/ pruritus/high
colored urine
 No h/o fever/ shortness of breath
 No h/o altered bowel habits

6.  h/o hospitalization
(1week) for similar
complaints 6 years
back +
 Managed
conservatively
 No other
comorbidities
 No h/o similar
complaints in the
family
Past history Family history

7. Personal history
 Alcoholic - 50g/day , H/o binge intake prior
to pain abdomen +
 Smoker – 1 pack/ day, 16 pack years
 Consumes mixed diet

8. General physical examination
 Moderately built & nourished, conscious, well
oriented
 BMI 20.2kg/m2
 No pallor icterus, cyanosis, clubbing, edema
and lymphadenopathy
 BP- 100/70mmhg
 Pulse rate- 96bpm
 Respiratory rate- 18/min

9. Abdominal examination
 Abdomen scaphoid shape, umbilicus centrally
placed, corresponding quadrants move equally
with respiration, no visible scars, sinuses or
veins
 Soft , epigastric tenderness present, no
organomegaly
 No e/o free fluid
 Bowel sound were normally present
 Per rectal examination: Normal fecal staining

10. Investigations
 Hb- 11.2g/dl
 TLC - 5700cells/mm3
 Platelets- 3.04lakhs
 ESR- 35mm/hr
 RFT- 42/ 1.0
 LFT- 0.8/ 23/17/72/6.6/4.0/2.6
 Amylase- 329 IU/ml

11.  HIV/ HBsAg/Anti-HCV Negative
 HDL- 48mg/dl, TGs- 110mg/dl, LDL- 80mg/dl
 Serum Calcium: 8.1mg/dl
 CA 19.9- 35 U/ml
 Chest Xray : Normal
 USG Abd: Head of pancreas appears
obscured, multiple calcifications noted in the
pancreas

15. CECT- ABDOMEN
 Multiple coarse calcification notes in
pancreatic parenchyma and intraductal region
of head and uncinate process
 MPD appears dilated(7.7mm) with multiple
side branch ectasia
 Inflammatory changes and cystic fluid
collection noted in pancreatico-duodenal
groove
Acute on chronic pancreatitis , s/o groove
pancreatitis

16. VOGD

17. Histopathology
 Chronic non specific duodenitis with Brunner
gland hyperplasia

18. Management
 Patient was managed conservatively with
intravenous fluid , analgesics and PPI
 Patient symptomatically improved
 Discharged with stable vitals
 Planned to redo VOGD after 6 weeks

19. Discussion

20. Introduction
 Under recognized form of recurrent or chronic
pancreatitis
 characterized by scarring in the ‘‘sliding
plane,’’ between the duodenum and the head of
the pancreas
 Mimic periampullary or pancreatic carcinoma.
 Potet and Duclert in 1970- cystic dystrophy of
the duodenal wall developing in the heterotopic
pancreas
 Becker : Rinnenpankreatitis- German
 Stolte : groove pancreatitis
Stolte M et al special form of segmental pancreatitis: ‘‘groove pancreatitis.’’
Hepatogastroenterology. 1982

21. Synonyms
 Myoadenomatosis
 Cystic dystrophy of heterotopic pancreas
 Para-duodenal wall cyst
 Pancreatic hamartoma of duodenum
 Paraduodenal pancreatitis
Adsay NV, Zamboni G. Paraduodenal pancreatitis Semin Diagn Pathol. 2004; 21(4):247–254.

22.  Stolte et al. classified groove pancreatitis into a
1. Pure form- scarring is localized to the
groove
2. Segmental - scarring extends dorsocranial
portion of the pancreatic head
 Because of its rarity, the distinct incidence of
groove pancreatitis is unknown
Stolte M et al special form of segmental pancreatitis: ‘‘groove pancreatitis.’’

24. Pathogenesis
 Anatomic disruption: absence or functional
obstruction of the minor papilla
 Pancreatic heterotopia: in the duodenal wall
because of incomplete involution of the dorsal
pancreatic head localized inflammation,
cicatrisation cystic dystrophy, and duct ectasia.
 Chronic alcohol consumption leading to increased
intraductal pressure in the accessory duct with
leakage into the groove.
Shudo R et al. Groove pancreatitis accompanied by protein plugs in Santorini’s duct. J
Gastroenterol

25. Clinical features
 Middle-aged men
 History of alcohol abuse and smoking
 Women and other age groups are rarely
reported
 The stenotic duodenal wall and exocrine
pancreatic dysfunction - constellation of
gastrointestinal symptoms and weight loss.

26. Clinical features
 Severe upper abdominal pain, nausea, and recurrent
postprandial vomiting, which occurs for weeks to
several years, with resulting weight loss.
 Characteristic manifestations is duodenal stenosis,
severe and patient presents with obstructive
symptoms.
 Tubular stenosis of the common bile duct is
frequently described, obstructive jaundice is rare,
with delayed presentation compared with cases of
pancreatic adenocarcinoma.
Tarvainen T et al., HPB,2020

27. Diagnosis
 Serum pancreatic (amylase, lipase) elevated
 Serum levels of carcinoembryonic antigen and
carbohydrate antigen (CA 19-9) are usually normal
 Upper gastrointestinal scopy shows erosion redness,
stenosis due to edema, and a polypoidal appearance in
the duodenum
 Transduodenal biopsy is important to distinguish
peripancreatic cancer from groove pancreatitis
Chute DJ, Stelow EB. Diagn Cytopathol. 2012;40(12):1116–1121.

28. CT ABDOMEN
 Hypoattenuating, poorly enhancing soft-tissue
mass is seen in the P-D groove, which represents
scar tissue.
 Duodenal wall- diffuse or eccentric thickening,
accompanied with cysts of varying size and
shape, in the duodenal wall and/or the groove
area
 Duodenal stenosis is observed less commonly
 Enlargement of a single cyst may mimic intestinal
Perez-Johnston R et al. Radiol Clin North Am 2012 May;50(3):447e66.

29. MRCP
 Widening of the space between the duodenal lumen
and the distal CBD and PD
 Intramural and paraduodenal cysts
 A long segmental smooth distal CBD stenosis as
opposed to an irregular stricture with shouldering in
groove carcinomas
 Dilatation of Santorini’s duct and its branches with
depiction of intraductal signal voids representing
calculi or protein plugs
Perez-Johnston R et al. Radiol Clin North Am 2012 May;50(3):447e66.

30. EUS
 Preferred imaging method
 Hypoechoic area b/w duodenal wall and the
pancreatic parenchyma, thickening and
narrowing of the duodenal lumen, associated
pancreatic calcifications and dilatation of the PD
 Diagnosis can be confirmed by EUS-guided FNA
in cases where imaging findings overlap with
pancreatic groove carcinoma.
Rahman SH, Verbeke CS, Gomez D, et al. HPB 2007;9:229e34.

31. Tarvainen T et al., HPB,2020

32. Tarvainen T et al., HPB,2020

33. Groove Pancreatitis
Pancreatic Adenocarcinoma
 Hypoechoic mass
between pancreatic
head and
duodenum,
duodenal wall
thickening, cystic
changes, and
stenosis, normal-to-
mildly dilated
common bile duct
 Pancreatic head
mass, with or
without dilation of
common bile duct
and/or pancreatic
duct
Groove Pancreatitis Vs
Adenoca
CECT
A. Arora et al. Clinical Radiology 69 (2014) 299e306

36. Groove Pancreatitis Pancreatic Adenocarcinoma
 Sheet-like mass in
groove, duodenal
thickening, common
bile duct stenosis
 Enlarged mass
mostly in pancreatic
head, with widening
of the space between
the distal pancreatic
duct and common
bile duct and
duodenal lumen
MRI
A. Arora et al. Clinical Radiology 69 (2014) 299e306

37. Groove
pancreatitis
Pancreatic
carcinoma
Appearance Sheet like mass Round , irregular
Stenosis of bile duct Smooth and long Abrupt and short
Cystic lesions More often less
Encasement of vessels No encasement Encasement
present
Thickening of duodenal
wall and duodenal
stenosis
Frequent Not common
Biliary dilatation Infrequent Frequent Biliary
stricture
Locoregional adenopathy Absent Present
A. Arora et al. Clinical Radiology 69 (2014) 299e306

38. TREATMENT
 Abstinence from alcohol and tobacco
 Opioid analgesics are the most frequently used
 Surgery is the treatment of choice when
symptoms do not improve, or the condition is
difficult to distinguish from pancreatic carcinoma.
 Surgical procedures comprise pancreato-
duodenectomy and pylorus-preserving
pancreatoduodenectomy
Isayama H et al. Gastrointest Endosc. 2005;61(1):175–178.

39.  One report described curing GP by endoscopic
drainage of minor papilla, which may be an
effective treatment in a subset of patients
 Relief was temporary because new cystic areas
developed, and the patients eventually needed
surgical therapy
 Endoscopic therapies can be used as ‘‘bridge’’
treatments before definitive surgery could be
performed.
Isayama H et al. Gastrointest Endosc. 2005;61(1):175–178.

40. Take home message
 Groove pancreatitis should be kept in mind when making
the differential diagnosis between pancreatic masses and
GOO
 In all cases of focal pancreatitis involving the head or
uncinate process of the pancreas with involvement of the
adjacent duodenum, the possibility of groove pancreatitis
should be considered.
 If the duodenal wall is thickened and cysts are present in
the groove region in a middle-aged patient with chronic
alcohol consumption, groove pancreatitis should be kept
in mind.