An Unusual Cause of Acute Pancreatitis

Question: A 39-year-old man with a past medical history of gastroesophageal reflux disease, well controlled on esomeprazole 40 mg daily, presented to an outside hospital with intermittent epigastric abdominal pain starting a week prior. His pain worsened and became constant, prompting him to go to the outside hospital. He had associated nausea, but denied any blood in his stool. He admitted to drinking a couple of cans of beer 2–3 times a week. Physical examination revealed normal vital signs, and a soft nontender abdomen. Laboratory studies showed white blood cell count of 8.6 × 109/L (reference, 4.0–10.0 × 109/L), hemoglobin of 11.3 g/dL (reference, 13.5–17.0 g/dL), platelets of 361 × 109/L (reference, 150–400 × 109/L), aspartate transaminase of 23 U/L (reference, 15–37 U/L), alanine transaminase of 51 U/L (reference, 12–78 U/L), and lipase of 442 U/L (reference, 73–393 U/L). A computed tomography (CT) scan of the abdomen showed mild acute pancreatitis findings and fullness of the pancreatic head without a definitive mass. The patient was discharged home with instructions to change diet to low-fat, and an outpatient endoscopic ultrasound (EUS) was scheduled the following week with our service. During EUS, the ampulla appeared as in Figure A. The pancreatic head appeared as in Figure B including color Doppler characteristics. A CT angiogram of the abdomen was then obtained to further characterize this mass (Figure C).