Typical Case 3:Chronic Pancreatitis with Pancrea...
Fig.13.5 MRCP revealed segmental dilatation of the main pancreatic duct，mild peripancreatic fluid collections with the pancreas poorly demarcated
Brief history:a 52-year-old man complained of recurrent upper abdominal pain for 1 year and aggravated for 1 month.In 2010，he presented with persistent upper abdominal pain concurrently with fever and nausea under no obvious precipitating causes.Blood tests in the local hospital showed a high serum amylase level and CT suggested pancreatic duct stones and an acute episode of chronic pancreatitis.Therefore，antacids，trypsin inhibitors and anti-inflammatory agents were administered to improve the symptoms.Since then，the pain had recurred for several times，relieved by fasting each time.Due to much more frequent bouts in the past month，the patient was admitted to our department for further management.Weight had been reduced by 8 kg since the onset of the pain.
Physical examination:soft abdomen with epigastric tenderness，no rebound tenderness or guarding.
Laboratory parameters: triglyceride 1.93 mmol/L，HbA l c 6.4%，serumamylase 293 U/L，and negative results of IgG4.
CT:atrophy in thepancreatic body and tail，bead-like dilatation of the main pancreatic duct，a cystic density lesion with clearly defined margins measuring 5.6*4.7 cm in the pancreatic neck，nodular and punctuate high-density shadows in the pancreatic head and body，and peripancreatic fluid collections（Fig.13.8）.
MRI and MRCP:significant atrophy in the pancreatic body and tail，bead-like dilatation of the main pancreatic duct，and a cystic density lesion with clearly defined margins measuring 5.6*4.7 cm in the pancreatic neck（Fig.13.9）.
Fig.13.6 （a）Endoscopy showed the major papilla on the descending duodenum after EPT.（b）Endoscopy showed pancreatic duct stent placement（5 Fr，7 cm）
Fig.13.7 （a）ERCP demonstrated the main pancreatic duct stricture at the junction of the head and body with upstream dilatation.（b）ERCP demonstrated that pancreatic duct stent had passed through the stricture
Fig.13.8 CT revealed atrophy in the pancreatic body and tail，bead-like dilatation of the main pancreatic duct，a cystic density lesion with clearly defined margins measuring 5.6*4.7 cm in the pancreatic neck，nodular and punctuate high-density shadows in the pancreatic head and body，and peripancreatic fluid collections
Fig.13.9 MRI and MRCP revealed significant atrophy in the pancreatic body and tail，bead-like dilatation of the main pancreatic duct，and a cystic density lesion with clearly defined margins measuring 5.6*4.7 cm in the pancreatic neck
Diagnosis:an acute episode of chronic pancreatitis，pancreatic pseudocyst.
Treatment process:after conservative treatment，ERCP+EST was carried out on 17 January 2011，followed by ESWL on 31 January，6 February and 7 February respectively.Then，ERCP+EPT+bougienage+stent placement across the connection between the pseudocyst and accessory pancreatic duct was performed on 8 February（Figs.13.10 and 13.11）.Three months later，CT showed a decrease in the volume of the pseudocyst（Fig.13.12）.
Fig.13.10 （a）Endoscopy showed the major papilla on the descending duodenum after EPT and the repeated insertion of a guidewire into the accessory pancreatic duct.（b）Endoscopy showed stent insertion into the accessory pancreatic duct（8.5 Fr，7 cm）(https://www.daowen.com)
Fig.13.11 （a）After the injection of contrast medium into accessory pancreatic duct，ERCP demonstrated the pancreatic duct well:stricture in the head，irregular distortion and dilatation in the body and tail，and a pseudocyst measuring 5.6*4.7 cm that communicates with the accessory pancreatic duct in the pancreatic neck.（b）ERCP demonstrated that the stricture in the pancreatic head had been dilated after bougienage and the stent had been placed across the connection between the pseudocyst and accessory pancreatic duct
Fig.13.12 CT revealed a decrease in the volume of the pseudocyst，atrophy in the pancreatic body and tail，and the post-ERCPpancreatic duct after stent placement
Fig.13.13 CT revealed pancreatic duct dilatation，multiple low-density shadows in the pancreatic head and tail suggestive of pancreatic pseudocysts up to 7 cm in diameter