Case 3
A 35-year-old male with no known co-morbids, presented with the complaints of epigastric pain for 2 days. On examination the abdomen was mildly tender in the epigastric region otherwise soft and without rebound tenderness. The rest of the examination was unremarkable. Early laboratory investigations including complete blood count, lipase, amylase, and liver function tests were within the normal range (Serum amylase was at the upper limit of normal). CT abdomen with contrast showed a mildly enhancing soft tissue density mass involving the head and uncinate process of the pancreas completely encasing the superior mesenteric artery. Mild peripancreatic fat stranding and inflammatory changes extending into the mesentery along with prominent peripancreatic lymph nodes were also noted. Scan was concluded as acute on chronic pancreatitis. The possibility of intraductal papillary mucinous tumor was also raised. His serum CA19-9 (non-detectable to 39 U/mL) and CEA (0-3.0 ng/mL healthy subjects) were 162 and 2.25 respectively. Endoscopic retrograde cholangiopancreatography (ERCP) showed filling defects in the distal common bile duct (CBD) consistent with sludge. CBD was cleared from the sludge with repeat cholangiogram showing no filling defect. Pancreatic duct could not be cannulated. The patient was discharged in a stable condition. CT abdomen performed 4 years later redemonstrated the same findings with interval progression. This time the infiltrating lesion was seen encasing the portal vein and hepatic artery (Figure 3 ). The conclusion of the scan was neoplastic lesion with remote possibility of IgG4 related disease. CT guided transhepatic core biopsy of the pancreatic lesion was performed. Histopathology reported linear cores of fibrocollagenous tissue exhibiting dense mixed inflammation with small abscesses and no evidence of malignancy (Figure 4 ). Serum IgG-4 level was 2960 mg/L. Patient has not paid a follow up visit after this.