A0074 - A Unique Endoscopic Presentation of Intraductal Papillary Mucinous Neoplasms (IPMN) Presenting as a Hemorrhagic Mass

Harsh Patel, MD, MPH¹, Sarah Huang, MD¹, Dean Rizzi, MD², Navim Mobin, MD¹, Yani Zhao, MD³, Shah Giashuddin, MD⁴, Mukul Arya, MD^5
1NewYork Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY; ²New York Presbyterian Brooklyn Methodist, Brooklyn, NY; ³Long Island Jewish Medical Center at Northwell Health, Queens, NY; ⁴NYP Brooklyn Methodist Hospital, Brooklyn, NY; ⁵NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY

Introduction: Pancreatic Intraductal papillary mucinous neoplasms (IPMN) are mucinous lesions of the pancreatic duct, accounting for approximately 1% of all pancreatic neoplasms and one fourth of cystic neoplasms. Three types exist: main duct IPMN, branch duct IPMN, and mixed-type IPMN. IPMN is a histologically benign tumor with the potential to be precancerous, and subsequently progress to pancreatic ductal adenocarcinoma. Given the potential of progressing from low-grade dysplasia to invasive carcinoma in approximately 4-6 years, early detection can improve prognosis. They may be asymptomatic or cause abdominal pain, nausea, vomiting, weight loss, jaundice, and pancreatitis. Diagnosis is by CT, MRI, or, in some cases endoscopic ultrasound (EUS) with fine needle aspiration (FNA), followed by biochemical and histopathological analysis.

Case Description/Methods: We report a 45 year old female with a history of hypertension, who presented to our hospital after outside imaging showed a pancreatic mass on CT abdomen and pelvis. EUS was performed, which showed an irregular, 10-mm mass with well-defined borders in the main pancreatic duct. There was no abnormality of the common bile duct and no stones identified. The patient subsequently underwent an ERCP one month later, which showed moderate dilation of both the ventral pancreatic duct in the head of pancreas and main pancreatic duct. A 12-15 mm hemorrhagic “cauliflower” mass was also found which was oozing and friable. Biopsy was consistent with intraductal papillary mucinous neoplasm. The patient subsequently underwent a successful Whipple procedure. Surgical pathology returned showing intra-ampullary papillary tubular neoplasms (IAPN) with high grade dysplasia, and resection margins negative for neoplasm.

Discussion: With technological advancements in radiographic and endoscopic imaging, the incidence of IPMN has increased. CT fish mouth ampulla sign (continuous water attenuation from the pancreatic duct to the duodenal lumen) and endoscopic fish mouth ampulla (E-FMA) signs are highly specific for main duct and mixed IPMN. Our patient’s findings are unique in that her ERCP showed a hemorrhagic mass representing an unusual presentation of a common pancreatic lesion. Additionally, we aim to illustrate the importance of early endoscopic evaluation with endoscopy in patients with pancreatic changes on cross sectional imaging. The malignant potential for main duct IPMN is greater than for branch and mixed type IPMNs and therefore more commonly surgically resected.



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Harsh Patel, MD, MPH¹, Sarah Huang, MD¹, Dean Rizzi, MD², Navim Mobin, MD¹, Yani Zhao, MD³, Shah Giashuddin, MD⁴, Mukul Arya, MD⁵. A0074 - A Unique Endoscopic Presentation of Intraductal Papillary Mucinous Neoplasms (IPMN) Presenting as a Hemorrhagic Mass, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.