Post written by David Albers, MD, from the Department of Gastroenterology, Elisabeth-Krankenhaus Essen, academic teaching hospital of the University of Duisburg-Essen.

Main-duct-IPMN and mixed-type-IPMN are frequently associated with malignancy and usually leaded to surgery; however, branch-duct-IPMNs biologically behave more indolent. Prediction of malignancy is a crucial point to distinguish between surgical therapy and conservative management in this heterogenous group of cystic neoplasia. In small lesions, the standard diagnostic tools can fail to judge the pathologic lesion. We report on a 58-year-old female with pancreatic carcinoma in her family history who presented with two cystic lesions recognized by MR-imaging for diagnostic work-up. In  EUS-scan, a mild dilation of the main pancreatic duct measuring 3.5 mm in the head and 4.5 mm in the body was identified. Two cystic structures between 10-13 mm with small wallstanding nodules and wall-thickening were detected. The connecting branch-ducts leading from the cystic lesions to the main pancreatic duct could be clearly identified. To discriminate between debris and neoplasia, a CE-EUS was performed showing no perfusion in the suspected areas. In performing a digital pancreatoscopy, the diagnosis of a mixed-type IPMN could be ensured. In this video, we show the digital pictures from inside the organ and put them in relation to MR-imaging and EUS-images. We consider the video to be useful for other endoscopists to get an orientation in endoscopic ultrasound and to understand anatomic relations.

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