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Special Feature
September 21, 2009

Image of the Month—Quiz Case

Author Affiliations

Copyright 2009 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2009

Arch Surg. 2009;144(9):877-878. doi:10.1001/archsurg.2009.155-a

A 63-year-old white woman presented with a 48-hour history of colicky epigastric and right upper quadrant pain with radiation to her back, low-grade fever, nausea, and vomiting. The patient's medical history was significant for congestive heart failure, hypertension, asthma, sarcoidosis, and scleroderma. Her social history was significant for residing in Durango, Colorado, where a large uranium plant is located. On physical examination, her abdomen was soft with reproducible right upper quadrant and epigastric tenderness. Laboratory results on admission were as follows: leukocyte count, 11 900 cells/μL (to convert to ×109L, multiply by 0.001); hemoglobin, 15.5 g/dL (to convert to grams per liter, multiply by 10.0); platelets, 26.6 × 104cells/μL; aspartate aminotransferase, 115 U/L (to convert to microkatal per liter, multiply by 0.0167); alanine aminotransferase, 266 U/L; alkaline phosphatase, 146 U/L; total bilirubin, 1.6 mg/dL (to convert to micromoles per liter, multiply by 17.104); direct bilirubin, 0.6 mg/dL; prothrombin time, 13.2 seconds; international normalized ratio, 0.93; partial thromboplastin time, 26.1 seconds; amylase, 52 U/L; and lipase, 32 U/L. Ultrasonography, computed tomography of the abdomen (Figure 1), and magnetic resonance cholangiopancreatography revealed a mass in the pancreatic head as well as dilation of the common bile and pancreatic ducts. A stent was placed in the pancreatic duct via endoscopic retrograde cholangiopancreatography without symptomatic relief. She was then taken for pancreaticoduodenectomy (the Whipple procedure) with J-tube placement. In the surgical specimen, a solid tan mass in the pancreatic head with central necrosis was found, measuring 2.5 × 2.4 × 2.2 cm in greatest diameter. Histopathology is shown in Figure 2.

Figure 1.
Pancreatic head mass.

Pancreatic head mass.

Figure 2.
Hematoxylin-eosin–stained histopathology.

Hematoxylin-eosin–stained histopathology.

What Is the Diagnosis?

A. Zollinger-Ellison syndrome

B. Insulinoma

C. Giant cell tumor

D. Pseudocyst