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Forum Name: Gastroenterology Topics

Question: Pancreatic head mass, MRI VS. Ultrasound?


 kathryn6323 - Thu Apr 30, 2009 11:34 pm

I am a 25 year old white female, 68 inches, 132lbs. I had an abdominal ultrasound due to complaints of weight loss (usually 145-150lbs), nausea and a stinging pain in the upper right portion of my abdomen near my rib cage. The pain has existed for several years (ultrasound and upper GI normal at that time) but the other symptoms are about 6 months new.
I had an upper GI a few days ago that showed a small duodenal ulcer off the superior aspect of the bulb. The same day I had an ultrasound that showed a focal hypoechoic mass in the anterior head of the pancreas measuring 1.1 x 1.1 x 0.6 cm. The pancreatic duct was at the upper limits of normal measuring 3 mm in diameter. It was noted as suspicious for neoplasm and could represent either a primary neoplasm of the pancreatic head or abnormal adenopathy adjacent to the head of the pancreas. Further evaluation was recommended with MRI of the abdomen. I had the MRI today and was told that it was completely normal.

Since the MRI was normal does that mean there isn't anything in my pancreas, there is nothing wrong with me and the ultrasound was false? Is the MRI the deciding factor of whether something is there or not? Are there any other tests that can give a definitive answer? CT scan?

Is there any significance in my pancreatic duct being normal but on the upper limits of normal in relation to where the mass was in the head of the pancreas?

All my lab and blood tests were normal. My TSH was 0.3 uIU/ml. Which I understand is normal but is the lowest that is allowed as normal. Is there any significance?

I feel a little pain primarily on the right side but I also feel a lighter pain on the left side. Is the location of the duodenal ulcer in the superior aspect of the duodenal bulb close to the head of the pancreas? Could the ulcer have been what they saw on the ultrasound based on it's reported location? How could this be if I have two separate feelings of pain in my abdomen on the left and the right?

I am still having these symptoms, what do you suggest I do?
 John Kenyon, CNA - Fri May 08, 2009 11:24 pm

User avatar Hi there --

This is a much more complex question than it might have been, had the MRI been done first. I'll explain: generally MRI is performed first and if there is any abnormality seen, endoscopic US is recommended for followup, because it will clarify what may or may not have been seen on MRI, with very high specificity, accuracy and sensitivity. So is MRI in many parts of the anatomy, but apparently not as much so for the sort of tissues involved in the specific area of the duodenum and HOP. Since US is usually used for second look confirmation and the MRI was done first, this somewhat confuses the issue for you. Further, the duodenum can rest quite close to the HOP, and you do have an ulcer there, only further complicating the picture.

The findings near (but within) the limits of normal are fine. The line simply has to be drawn somewhere, and there is some wiggle room with these when and if the are outside normal limits. Yours were not, so that is not a concern.

My recommendation would be, due to the potential, however remote, for something more to be going on with the pancreas, especially in terms of some sort of neoplasm, that you seek an endoscopic ultrasound to confirm (or not) the MRI's findings, since a regular abdominal US may well not expose what's there (or not there) with near the specificity of endoscopic US. In fact, you may as well have both areas examined at once via endoscope, since this will also give a far more clear picture of what's been diagnosed as a duodenal ulcer. Upper GI should be followed by more specific testing anyway. I wouldn't recommend this except that you have a suggestive abdominal US finding complicated by a nearby duodenal lesion and this is too critical an area to just take for granted. You can come away from this either with a completely clear mind or at worst be far ahead of any neoplastic growth, as unlikely as this may be, as early is virtually the only effective time to attack those when present, even if benign.
While I strongly suspect this would all come out just as it appears on the original tests, I cannot with a clear conscience advocate you just taking this as the last word. It is a personal prejudice of mine, but based on experiences that could have turned out far better. I'm always in favor of ruling out the most serious possibiliites first.

I hope this is helfpul. Good luck to you and please follow up with us here, and also keep us updated. Good luck to you.
 kathryn6323 - Sun May 10, 2009 12:17 pm

I am going to seek a CT scan and an endoscopic ultrasound just to be sure. It was also recommended that I do a gastroscopy as well. Which of these three tests would you recommend that I have done first since the ultrasound shows the pancreatic mass and the MRI does not? I am glad I asked because when the MRI results came back normal my Doctor acted as if that was the final say in the issue and nothing was there. Whereas I am more skeptic about the MRI. I would like to have more tests done to be sure but not sure if I should proceed first with a CT scan, an endoscopic ultrasound, or a gastroscopy. I have to say I am a little weary about having a tube shoved down my throat but I will do whatever that will give me the final answer if something is in my pancreas or not. Should I talk to a gastrointerologist about this rather than just my family doctor since she has the attitude that the MRI is fine and therefore nothing is in my pancreas? They also said the ultrasound that saw the mass could have picked up my duodenal ulcer. Will these tests differentiate between the ulcer and an actual pancreatic mass even though the areas are so close together? I'm not so worried it's cancer because my liver and blood labs were fine but I will stay on top of it because I know how sensitive the pancreatic cancer can potentially be. Thank you so much for your information it was much more helpful than my family doctor.
 John Kenyon, CNA - Sun May 10, 2009 8:26 pm

User avatar While there is an even chance there is something or nothing in your pancreas, or a 50/50 chance of there being nothing, it's like tossing a coin to accept the MRI uncritically, and while some areas are less problematic, this is, as you seem to know, an area where one cannot afford to flip a coin. Better a little inconvenience now than to find out there was something overlooked. Given the enormous credit given endoscopic ultrasound in this particular area, I would probably, were it me, go this way: Have the CT scan done (could be a tie-breaker, but only if it "sees" something, not if it's negative) with the intention of going forward with the endoscopic US. With the mild sedation used, it's really not as uncomfortable as one might expect, and actually is often not remembered at all by the patient. I do think also you would do well to let an ENT specialist take over on this, not only because of the greater insight into diagnostic techniques and disease processes, but because your GP seems too ready to take the negative result as the correct one when it's already been done in a reverse fashion. Better to let an ENT sort out the existing test results, then decide how best to proceed. It may be the ENT will concur with the present finding, and if so, then it would be coming from someone who does this specifically for a living. I'd feel better with that for sure.

Endoscopic US will definitely be able to discriminate between the ulcer and anything possibly present in the HOP despite the proximity. This is one more reason it's highly specific for this sort of situation. While the odds are slightly in favor of a negative discovery (nothing there), it would be far better to have an ENT make the call and I suspect the endoscopic US would be wanted to be certain. You're currently in generally good health, so this is a huge advantage if there should be something found, and of course if there's not, then that's reason to just exhale and celebrate.

Good luck to you. Please stay in touch.

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