Pancreatic Arteriovenous Malformation
A 59-year-old man was admitted to our hospital with intermittent upper abdominal pain. He had a history of cervical disc herniation, lumbar compression fracture and abdominal aortic aneurysm. Physical examination revealed slight tenderness in the left upper quadrant of the abdomen, and no masses were palpable. Laboratory data on admission showed: erythrocyte count 411 × 104/mm3 (normal 410–530), hemoglobin 13.7 g/dl (normal 14–18), leukocyte count 9,800/mm3 (normal 4,000–8,000), platelet count 27.1 × 104/mm3 (normal 15–40), serum total protein 6.8 g/dl (normal 6.5–8.0), total bilirubin 0.67 mg/dl (normal 0.2–1.0), aspartate aminotransferase 16 IU/l (normal 10–40), alanine aminotransferase 12 IU/l (normal 5–40), alkaline phosphatase 339 IU/l (normal 115–360), lactate dehydrogenase 256 IU/l (normal 119–229), γ-glutamyltranspeptidase 56 IU/l (normal 10–47), serum amylase 100 U/l (normal 33–116), blood urea nitrogen 14.0 mg/dl (normal 8–22), creatinine 0.8 mg/dl (normal 0.6–1.1), and C-reactive protein 1.71 mg/dl (normal 0–0.3). The serum level of the tumor marker carcinoembryonic antigen (CEA) was slightly elevated to 6.5 ng/ml (normal 0–5), and the carbohydrate antigen (CA19-9) level was elevated to 159.3 U/ml (normal 0–37).\nContrast-enhanced computed tomography (CT) showed numerous strongly enhanced abnormal vessels and a hypovascular lesion in the area of the pancreatic tail (fig. ). Angiographic study of the celiac artery confirmed racemose vascular networks in the tail of the pancreas and early venous return to the portal system (fig. ). Endoscopic retrograde pancreatography (ERP) revealed narrowing and displacement of the main pancreatic duct in the tail of the pancreas (fig. ). Screening esophagoscopy showed a 0-IIa+IIc type tumor in the lower thoracic esophagus and multiple Lugol-voiding lesions. Histological examination of esophagoscopic biopsies showed squamous cell carcinoma.\nBased on these findings, P-AVM and chronic pancreatitis or pancreatic cancer with esophageal cancer were diagnosed. Video-assisted thoracoscopic esophagectomy and distal pancreatectomy with partial transverse colectomy were performed. The operative time was 402 min, and the amount of blood loss was 956 ml. There was a honeycomb-like structure with collected vessels in the pancreas. The splenic vein was occupied by thrombi (fig. ).\nHistological examination of the resected pancreas revealed rupture of the dilated pancreatic duct with bleeding (fig. ), pancreatic stones (fig. ) and severe atrophy with fibrosis of the pancreatic parenchyma (fig. ). These findings were consistent with chronic pancreatitis. In addition, many abnormal vessels, some containing thrombi, were observed in the pancreas (fig. ). The final diagnosis was P-AVM consequent to severe chronic pancreatitis and esophageal carcinoma. The patient had an uneventful postoperative course, and CA19-9 levels normalized to 27.6 U/ml.