A 57-year-old man who suffered from upper abdominal pain for over 1 year and worsening for 2 months was admitted to a local hospital initially. He had progressive xanthoderma and lost 4 kg of weight in 2 months. This patient had a previous history of recurrent duodenal ulcer and alcohol abuse for over 30 years. Physical examination suggested right-upper abdominal pain and jaundice. The laboratory results of the local hospital showed a significant increase in the serum levels of carbohydrate antigen 19-9 (CA19-9; 160.3 U/L), total bilirubin (TBIL; 103.9 mumol/L), gamma-glutamyl transpeptidase (gamma-GT; 1,341 U/L), alkaline phosphatase (ALP; 687 U/L), alanine aminotransferase (ALT; 184 U/L), and aspartate aminotransferase (AST; 69 U/L). A rough patch of mucosa was found in the descending duodenal region through gastroscopy, and the following biopsy suggested chronic inflammation. In order to relieve the symptoms of jaundice, the patient underwent endoscopic retrograde cholangiopancreatography (ERCP) with stent deployment in the common bile duct at a local hospital.
He was transferred to our hospital for further evaluation and treatment. All the clinical indicators of laboratory results were better on his admission compared to the results before stent deployment (Figures 1A-C). A week later, the serum levels of TBIL, gamma-GT, ALP, ALT, and AST gradually decreased. In order to make a definite diagnosis, we performed further relevant tests. Abdominal computed tomography (CT) indicated a hyperdense mass in the common bile duct, which was the biliary stent. The pancreatic parenchyma is plump, and the adipose tissue around the pancreas is cloudy, which suggested the possibility of pancreatitis (Figures 1D, E). Magnetic resonance cholangiopancreatography (MRCP) also suggested pancreatitis and stenotic distal common bile duct, but periampullary cholangiocarcinoma was not excluded (Figure 1F). Positron emission tomography (PET)-CT did not show any signs of malignant lesions (Figures 1G, H). The remaining stent in the common bile duct and an inhomogeneous echo of pancreatic parenchyma were seen through endoscopic ultrasonography (EUS) (Figures 2A-D). However, the biopsy of the rough mucosa in the descending duodenal region still suggested inflammation (Figures 2E-H).
Finally, we suspected the diagnosis to be groove pancreatitis based on the above clinical information (Table 1). The patient's symptoms and results of laboratory investigations almost returned to normal after conservative treatments. We suggested he receive reexamination and have the stent removed after 1 month before he was discharged from the hospital.
One month later, he was admitted to our hospital again. All his laboratory results were normal except for the slight rise of carbohydrate antigen 19-9 (CA19-9). Unexpectedly, symptoms of upper abdominal pain recurred, and the results of laboratory investigations worsened after the stent was removed. Then he underwent the second EUS examination through which a lesion in the lower common bile duct was confirmed (Figures 3A-C). For further treatments, he underwent pancreatoduodenectomy and achieved favorable clinical results (Figure 3D). Based on the histopathological evaluation of resected specimen, the following diagnosis was confirmed as moderately differentiated adenocarcinoma of the common bile duct (Figures 3E, F).