Case Presentation: Patient with prior history of alcohol use presented with abdominal pain, nausea vomiting of 4 days duration. Labs were remarkable for elevated BUN 38 mg/dL, Creatinine 1.9 mg/dL, AST 50 U/L and lipase 771 U/L. CT abdomen and pelvis showed a poorly delineated mass within the head and uncinate process of the pancreas invading into the medial wall of the second portion of the duodenum with adjacent peripancreatic lymphadenopathy. These findings were highly suspicious of a neoplastic process. The patient was managed symptomatically and discharged home with instructions to follow up outpatient with Gastroenterology and Hematology-Oncology. Alcohol abstinence was strongly advised. He underwent an outpatient Endoscopic ultrasound with US-guided shark core aspiration that showed a diffusely hypoechogenic head of pancreas likely representing benign inflammatory changes suggestive of groove pancreatitis. Cytology showed atypical acinar cells (acinar pancreatic epithelium with prominent nucleoli). CA-19-9 was with within normal limits and follow-up CT scan of abdomen pelvis obtained 2 months later showed normal imaging appearance of the pancreas without imaging finding of pancreatitis.
Discussion: Groove pancreatitis is a rare form of chronic pancreatitis affecting the anatomical area of the pancreatic head, duodenum, and the common bile duct. Speculative pathophysiology includes anatomical or functional obstruction of the minor duodenal papilla or duct of Santorini along with increased viscosity of secretions suspected secondary to alcohol use. Long-term alcohol use has the strongest association with groove pancreatitis. Since groove pancreatitis can present as a pancreatic mass, it is extremely difficult to differentiate these entities based on imaging and even on FNA as a lot of times these patients undergo repeated US-guided FNAs with non-specific findings. As a result, a subset of these patients gets pancreaticoduodenectomy for definitive diagnosis. In our case, fortunately, EUS, cytology and CA 19-9 were reassuring of a benign etiology, therefore a conservative strategy with alcohol abstinence and watchful waiting was opted.
Conclusions: Hospitalists are frequently required to manage alcoholic pancreatitis and Groove pancreatitis often masquerades as pancreatic cancer. Groove pancreatitis should be considered in alcoholic patients with a pancreatic mass at the head of the pancreas. EUS, FNA, CA-19-9 can be helpful in making the diagnosis in many cases. Abstinence of alcohol can result in complete resolution of symptoms and mass in some of the patients but others end up requiring surgical resection both for final diagnosis and symptomatic management.