Recurrent Self-Limiting Acute Pancreatitis: Intraductal Papillary Mucinous Neoplasm Requiring Surgery

Q: What features defined the patient’s recurrent acute pancreatitis episodes?

Each episode produced significant rises in serum amylase and lipase, with pain relieved by the knee-chest position, plus nausea and vomiting. Despite repeated attacks, both enzymes normalized within 2 days and there were no complications.

Q: How did imaging guide the diagnosis toward an intraductal papillary mucinous neoplasm?

Initial CT showed pancreatic swelling with localized infiltration, while MRCP later demonstrated a cystic neoplasm connected to the main pancreatic duct. Follow-up CT/MRCP showed cyst enlargement and main pancreatic duct dilation, supporting progression and need for resection.

Q: What treatment was performed and what did pathology confirm?

The patient underwent laparoscopic subtotal pancreatectomy in the 23rd month. Pathology confirmed intraductal papillary mucinous neoplasm (IPMN) with low-grade dysplasia, with both intestinal and pancreato-biliary type epithelium.

Sep 30, 2026

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A 70-year-old woman with type 2 diabetes presented with mild, dull epigastric pain that recurred more than 10 times, each episode showing marked amylase and lipase elevations but resolving spontaneously within 2 days without complications. Imaging began with CT showing pancreatic swelling and localized infiltration, followed by MRCP demonstrating a cystic neoplasm connected to the main pancreatic duct. Endoscopic ultrasound with through-the-needle biopsy showed cystic lesions and elevated cystic carcinoembryonic antigen without malignancy, while later CT/MRCP revealed cyst enlargement and main pancreatic duct dilation, prompting surgery. Laparoscopic subtotal pancreatectomy confirmed intraductal papillary mucinous neoplasm with low-grade dysplasia; postoperative recovery included a grade A pancreatic fistula, with no further acute attacks 2 years after surgery.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages2

Reading Time5 min

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Case presentation

Clinical course and laboratory findings

Imaging and diagnostic workup

Surgical management and pathology

Postoperative outcome

The Kaohsiung Journal of Medical Sciences Recurrent Self-Limiting Acute Pancreatitis: Intraductal Papillary Mucinous Neoplasm Requiring Surgery Chia-Hsin Chang1,2 | Yu-Chun Ma3 | Shih-Chang Chuang4 | Chih-Wen Wang1,2 1Division of Hepatobiliary, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan | 2Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan | 3Department of Pathology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan | 4Division of General and Digestive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan Correspondence: Chih-Wen Wang ([chinwin.wang@gmail.com](chinwin.wang@gmail.com)) Received: 26 March 2025 | Revised: 5 June 2025 | Accepted: 10 June 2025 A 70-year-old woman with Type 2 diabetes mellitus who denied alcohol or tobacco use presented with mild, dull epigastric pain. The pain was relieved by the knee-chest position and accompanied by nausea and vomiting, and she visited our emergency department after each episode. Significant increases in amylase (up to 4059 IU/L) and lipase (up to 6138 IU/L) levels recorded during over 10 visits for episodes of acute pancreatitis (Figure 1A) . Interestingly, both amylase and lipase levels returned to normal within 2 days after each episode without any complications, and her epigastric pain improved spontaneously. She was subsequently discharged without issues. Computed tomography (CT) during the first episode of pancreatitis revealed pancreatic swelling with localized infiltration (Figure 1B) . One month after the initial presentation, magnetic resonance cholangiopancreatography (MRCP) showed a cystic neoplasm in the pancreatic body connected to the main pancreatic duct (Figure 1C) . Endoscopic ultrasonography (Figure 1D) with a through-the-needle biopsy from the stomach was performed in the 10th month, which revealed cystic lesions in the pancreatic body and elevated cystic carcinoembryonic antigen level, but no signs of malignancy. The procedure was complicated by acute pancreatitis, which resolved spontaneously within 2 days. CT and MRCP in the 14th month showed an enlarging cyst and dilation of the main pancreatic duct (Figure 1E) . A surgical intervention was ultimately considered necessary, and laparoscopic subtotal pancreatectomy was performed in the 23rd month. Immunohistochemical staining of the specimen revealed both intestinal and pancreato-biliary type epithelium. A pathological examination confirmed intraductal papillary mucinous neoplasm (IPMN) with low-grade dysplasia (Figure 1F) . Postoperative recovery was complicated by a grade A pancreatic fistula (Figure 1G), which was managed with retained drainage. Her condition gradually improved, and as of 2 years post-surgery she has not experienced any further acute pancreatitis attacks. In patients with acute pancreatitis, an abdominal examination may reveal Grey–Turner's sign or Cullen's sign in severe cases indicating retroperitoneal hemorrhage, while guarding or rebound tenderness may be present in more advanced cases such as necrotizing pancreatitis or secondary peritonitis. The differential diagnosis of acute pancreatitis is extensive and should be approached systematically, encompassing pancreatic, biliary, gastrointestinal, hepatic, cardiovascular, metabolic, toxic, infectious, and miscellaneous causes. Guidelines vary in their threshold for recommending surgery [1] . The International Association of Pancreatology (IAP) [2] and European [3] guidelines adopt a more aggressive stance, considering that even small enhancing nodules (< 5 mm) are potential indicators for resection. The American College of Gastroenterology (ACG) [4] and European [3] guidelines also incorporate biomarkers such as elevated CA 19-9 levels and new-onset diabetes into their ris

FAQs

What features defined the patient’s recurrent acute pancreatitis episodes?

Each episode produced significant rises in serum amylase and lipase, with pain relieved by the knee-chest position, plus nausea and vomiting. Despite repeated attacks, both enzymes normalized within 2 days and there were no complications.

How did imaging guide the diagnosis toward an intraductal papillary mucinous neoplasm?

Initial CT showed pancreatic swelling with localized infiltration, while MRCP later demonstrated a cystic neoplasm connected to the main pancreatic duct. Follow-up CT/MRCP showed cyst enlargement and main pancreatic duct dilation, supporting progression and need for resection.

What treatment was performed and what did pathology confirm?

The patient underwent laparoscopic subtotal pancreatectomy in the 23rd month. Pathology confirmed intraductal papillary mucinous neoplasm (IPMN) with low-grade dysplasia, with both intestinal and pancreato-biliary type epithelium.

Sep 30, 2026

Uploaded by Riley