Enrique de-Madaria Profile picture
Oct 16, 2022 27 tweets 18 min read Read on X
Sometimes pancreatitis involves the duodenum, let´s talk about paraduodenal/groove pancreatitis
Don't miss this #GItwitter thread based on my talk for @harvardmed @HMSPostgradCE #HarvardMINT2022 course
Thanks, @CharuParanjape @krishnanendo for one of my best experiences ever!
Pancreas inflammation involving the duodenum has many names: Cystic dystrophy on aberrant pancreas of the duodenal wall, Groove pancreatitis... Adsay and Zamboni proposed paraduodenal pancreatitis as a term that involves these 2 organs
There are 2 important concepts:
1) The pancreatic-duodenal groove is the space between the duodenum and the pancreas: vessels, lymph nodes, Wirsung, Santorini, CBD & some acini are there. Those acini can suffer from pancreatitis: that`s groove pancreatitis
2) Some people have ectopic pancreatic tissue within the duodenal wall, those acini may have inflammation
Prof. Becker looked for surgical specimens with groove inflammation among 600 chronic pancreatitis patients who underwent Whipple procedure, 20% had groove involvement: 2% pure, 7% groove+pancreatic head involvement, 11% groove + classic chronic pancreatitis
Most patients with paraduodenal pancreatitis have alcoholic + smoke etiology for their pancreatic inflammation (and that´s my experience)
According to 1 single center study 0.18% of all pathology samples have digestive wall heterotopic pancreatic tissue, in 25% cases in duodenum/proximal jejunum
sciencedirect.com/science/articl…
When that ectopic acini within the duodenal wall become inflamed, we had what has been called cystic dystrophy on ectopic pancreas of the duodenal wall: cysts within the duodenal wall, thickened duodenal wall, this can be seen very well by EUS @japariciot2 @Belenmm271
Have a look at these interesting surgical specimens from Egorov and Vujasinovic/Verbeke
👇
This is a groove pancreatitis from one of my patients
Paraduodenal pancreatitis symptoms & signs: gastric outlet obstruction, jaundice, pain, weight loss and diarrhea (due to pancreatic exocrine insufficiency)
These are 2 patients from my center with duodenal stricture and delayed gastric emptying
In CT scan we can identify different patterns of paraduodenal pancreatitis:
- Pure cystic: this is the "cystic dystrophy of the duodenal wall"
- Solid-cystic: both
- Pure solid: that´s "groove pancreatitis"
The pancreatic gland may be involved or not, most patients will have pancreatic gland features of chronic pancreatitis
BE CAREFUL MY FRIEND, there is something evil called pancreatic groove adenocarcinoma, a pancreatic cancer involving the pancreatic duodenal groove
sciencedirect.com/science/articl…
These signs may help to differentiate malignant from benign stuff
This is the endoscopic view of paraduodenal pancreatitis, from my colleagues from @HospitalLaFe Pedro López Muñoz and @vicen_pons thieme-connect.com/products/ejour…
And you can see the USE findings in this video from Dario Ligresti and colleagues
thieme-connect.com/products/ejour…
Few studies have been published focused on paraduodenal pancreatitis management, have a look at this systematic review from Kager et al
journals.lww.com/jcge/Abstract/…
👇👇👇
Most patients with mild symptoms deserve conservative management, primum non nocere
Those with jaundice or cysts that are associated to symptoms can benefit from endoscopic treatment
Patients with PERSISTING pain without big cysts and those with PERSISTING gastric outlet obstruction may benefit from surgery when conservative treatment is not working
Some conclusions, I hope you liked the review and my drawings, all crafted with great excitement as my first @harvardmed @HMSPostgradCE collaboration!
Now it is time for you to retweet the first tweet of the thread 😁
@p_lopezmunoz crack gracias!

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More from @DeMadaria

Sep 14, 2022
Our dream comes true: the #WATERFALLtrial has been published in @NEJM Aggressive fluid resuscitation in acute pancreatitis is not safe & does not improve outcomes #GItwitter #SomosAEG @aegastro
What's behind this publication?
It all started 21 years ago
nejm.org/doi/full/10.10…
2001, I started to attend patients with acute pancreatitis as a GI resident in @GVAsalualicante. Books and papers recommended aggressive fluid resuscitation. It was believed that many fluids increased pancreatic blood flow preventing pancreatic necrosis
But I asked to myself, what is aggressive fluid resuscitation, how much fluids, and which type of fluids? I looked for specific data, but all was vague. I asked in GI meetings, and the answers of experts were vague, no specific fluid rate, just generalities
Read 28 tweets
Jul 30, 2022
1/5 @pancreatitis_nl trials addressing the management of infected pancreatic necrosis in acute pancreatitis #TheAmylaseSchool @my_ueg @EurPancClub @MarcBesselink #ClinicalResearch
2/5
Panther trial: A Step-up Approach or Open Necrosectomy for Necrotizing Pancreatitis @NEJM
This trial robustly demonstrated that minimally invasive treatment (percutaneous drainage and minim. invasive surgery if needed) was better than open surgery
nejm.org/doi/10.1056/NE…
3/5 Penguin trial: Endoscopic Transgastric vs Surgical Necrosectomy for Infected Necrotizing Pancreatitis @JAMA_current jamanetwork.com/journals/jama/… This trial showed that endoscopic necrosectomy was better (less aggressive) than open surgery
Read 9 tweets
Jun 26, 2022
Quick introduction to autoimmune pancreatitis, based on my recent talk in the @EurPancClub meeting #EPCKyiv2022 #GItwitter #TheAmylaseSchool #PancreasTwitter #PancreasLovers #MedTwitter
👇👇👇
Epidemiology
Presentation
Read 29 tweets
Apr 11, 2021
How to do a pro search in Pubmed?

This special #TheAmylaseSchool infographics (or mini-course) is a guide to navigate the deep waters of Pubmed (and not get drown). I provide a pdf at the end of the Twitter Thread

1/5
Author Journal Date Title Abstract Language Affiliation
👇 ImageImageImageImage
How to search in Pubmed 2/5
Mesh terms, Boolean operators, My NCBI filters
👇 ImageImageImageImage
How to search in Pubmed 3/5
How to save your search
👇 Image
Read 15 tweets
Feb 21, 2021
What is a Groove Pancreatitis (GP)? #GroovePancreatitis #ParaduodenalPancreatitis #CysticDystrophyDuodenalWall What are the symptoms, consequences, management?
Do not miss this @aegastro #HiloAEG #UEGambassador @my_ueg Twitter thread #TheAmylaseSchool Image
The groove area or pancreaticoduodenal groove involves the space between the duodenum, the head of the pancreas and the common bile duct karger.com/Article/FullTe… Image
Groove pancreatitis is a segmental chronic pancreatitis that affects the groove area; it was described in 1973 by Becker
link.springer.com/book/10.1007/9… Image
Read 15 tweets
Jan 3, 2021
Cross-sectional imaging often reveals unexpected pancreatic cystic lesions, it is a frequent clinical problem, Should we observe or remove it? What's the diagnosis? Is our patient in danger of malignancy?
Don’t miss this @aegastro @my_ueg #EducAEG #UEGambassador twitter thread
Importance of Pancreatic Cystic Neoplasms (PCN):
Most are asymptomatic at diagnosis, frequency increases with age
Symptoms: acute pancreatitis (Wirsung obstructed by the cyst or mucus), pain, obstructive chronic pancreatitis, jaundice
> symptoms, >malignancy risk!
Classification of PCN:
Mucinous: intraductal papillary mucinous neop. and mucinous cystic neop.
Nonmucinous: serous cystic neoplasm, solid pseudopapillary neoplasm and cystic neuroendocrine tumours
Endoderm- derived columnar epithelium is characteristic for mucinous lesions
👇
Read 18 tweets

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