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.