Case report:
A 26-year-old female presented to the outpatient department with history
of dull-aching, epigastric pain, radiating to the back for last
7-months. This was accompanied by early satiety and abdominal fullness
and progressed to non-bilious vomiting after taking food since last
7-days. There was no history of fever, weight-loss, jaundice, or altered
bowel habits. There was no relevant past or family history. Physical
examination was unremarkable. Laboratory investigations (complete
hemogram, serum electrolytes, transaminases, serum bilirubin) were
within normal limits. Contrast enhanced computed tomography of the
abdomen revealed a fairly enlarged pancreas. A 13.5x10.5x9.3 cm complex
cystic space occupying lesion (SOL) showing septation was seen (Figure
1). Main pancreatic duct was not dilated. Overall it was suggestive of
pancreatic cyst. To rule out any intraluminal cause of gastric outlet
obstruction, an upper gastrointestinal endoscopy was performed which was
unremarkable. An endoscopic ultrasound (EUS) was warranted to better
characterise the pancreatic SOL. It showed showed large exophytic
multiloculated cystic SOL with mural nodule arising from neck of
pancreas (Figure 2). EUS guided aspiration of cyst fluid was done which
showed cyst fluid amylase- 23U/L, CEA- 34.8ng/mL. Cytology revealed few
benign epithelial cells. Considering the provisional diagnosis as cystic
neoplasm arising from head of pancreas, Whipple’s pancreaticodudenectomy
was planned. Intraoperatively, we found distended gallbladder with
non-dilated common bile duct along with a 18x10x10 cm septated cystic
mass arising from inferior surface of segments IVB and V of liver
(Figure 3). It was having minimal peri-cystic adhesions and was free
from hepatoduodenal ligament. After careful adhesiolysis, and dividing
the feeding vessels, eneucleation of the mass was done from the liver
bed along with cholecystectomy. Resected specimen (Figure 4) was sent
for histopathological examination. It showed cyst wall lined by cuboidal
to columnar epithelium with apical mucin. Dense ovarian type of stroma
was seen without any cellular and architectural atypia. Overall it was
suggestive of mucinous biliary cystadenoma (Figure 5). She had an
uneventful recovery and was discharged on 7th postoperative day. She was
found to be well at 18-month follow-up.