So, for the next fellow, we're just going to go by alphabetically, Motazem Alkayad. Hello, everyone. Thanks for this great opportunity. When a dilated pancreatic duct is not just a chronic pancreatitis case, I would like to thank Dr. Isler, who helped me prepare the case. So, just to give a brief background, as you know, chronic pancreatitis is defined by radiographic criteria, such as radiodense calcification in the parenchyma or the duct, parenchymal atrophy, and pancreatic duct dilation. Pancreatic-type pain and history of acute pancreatitis usually reinforce the diagnosis in this context. And as we know, alcohol is usually the leading etiology for chronic pancreatitis. However, up to 30 percent of cases remain idiopathic or without clear cause. Tobacco, as we know, is associated with late-onset idiopathic chronic pancreatitis. However, always have a careful workup for etiology in the setting of idiopathic chronic pancreatitis. So, I'm presenting a case of a 77-year-old female patient who had history of cholecystectomy, and she's a tobacco smoker. She presented to the outside hospital for abdominal pain. Workup included normal lipase and liver tests, imaging done that showed features suggested for chronic pancreatitis, including diffusely dilated pancreatic duct, significant atrophy, and calcific changes mostly in the body and tail. MRCP confirmed the same finding and showed abnormally dilated duct and irregular up to 13 millimeters in the body and tail. And as you can see here in the CT scan, the pancreatic duct is dilated and dense calcification mostly in distal body and tail. So we proceeded with EOS and ERCP in the same session, and endoscopy showed normal duct in the head and dilated in the body up to 15 millimeters. Dense atrophy and pancreatic parenchyma calcification, distal stones in the body and tail. So for the ERCP, upon sweep, there was debris and mucus, and there was a concern for layering filling defect in the pancreatic body duct. So a decision was made to aspirate some of the fluid just to make sure there's no intraductal pathology. It was sent for CEA and cytology, and it came back unequivocal. So CEA was 112, and the cytology came back as benign ductal epithelial cells. So at this point, we decided to proceed to repeat the ERCP, but this time along with pancreatoscopy. So as you can see, previous sphincterotomy is open. After cannulating with an angled viscid wire, sweeping the duct, some debris, mucus came out, and the spy scope was advanced. And you can see some cloudy, mucousy material in the duct, and you can see the fluoroscopy showing how the spy scope is advancing. So on the way out, we saw projection-like tissue in the duct in the body, directed biopsies obtained, and fluoroscopy was used to map the duct to help with surgical planning. The pancreatic duct in the head was normal. This is the abnormal tissue in the duct. So biopsies came back as intraductal papillary mucinous neoplasm with low-grade dysplasia of intestinal type. Ultimately, the patient underwent distal pancreatectomy and splenectomy, and the surgical path confirmed the diagnosis, low-grade dysplasia, and all margins negative, including the 14 lymph nodes that were resected. Additional finding showed features of chronic pancreatitis, stones, and calcification. So in conclusion, IPMN can precipitate acute pancreatitis, and they can share radiographic features with chronic pancreatitis. Neoplasia, including IPMN, should be on the differential for patients referred for idiopathic chronic pancreatitis and or main pancreatic duct dilation. Have suspicion for IPMN in the setting of regional pancreatic duct dilation, either without or distant from the changes of chronic pancreatitis. Also have suspicion when there is viscous pancreatic duct fluid on sweep or layering filling defect on pancreatic crown. IPMN can verify the diagnosis, facilitate tissue biopsy, and more importantly, map the duct to help with surgical plan. And thank you.

idiopathic chronic pancreatitis

intraductal papillary mucinous neoplasm

distal pancreatectomy

ductal dilation

low-grade dysplasia