Case Description/Methods: A 32-year-old female with history of gastritis presents with stabbing, intermittent epigastric pain radiating to the back. In the past, she had presented to the emergency department for gastritis. Vitals notable for low-grade fever and tachycardia. She had no prior colonoscopy/EGD. Family history significant for colon cancer in dad at age of 70. Physical exam was remarkable for epigastric tenderness. Labs showed normal complete blood count, chemistry, liver function tests, lipase. Liver function test were mildly elevated with AST 40 and alkaline phosphatase 131. CT followed by MRI revealed multiple bilobar hepatic lesions, filling defects in the portal veins with periportal and perisplenic collateral, complex multiple masses from the pancreatic tail, the largest measuring 14.9cm (Figure). CA19-9, CEA, and AFP were negative. Esophagogastroduodenoscopy (EGD) and endoscopic ultrasound was done with fine-needle aspiration of the pancreatic mass. Histopathology was consistent with SPT. Discussion: The solid pseudopapillary tumor of the pancreas is an uncommon exocrine pancreatic tumor that accounts for less than 1% of all pancreatic tumors. Malignancy can arise in roughly 15% of instances, presenting as metastases or invasion of surrounding structures, despite the fact that majority show benign behavior. The most common metastatic sites are the liver and the omentum. They may present as an abdominal mass, jaundice, or abdominal pain as described in this case. The vast majority are found in the pancreatic body and tail. Ultrasound or CT scans are commonly used to diagnose them. In addition to a pre-operative pathology diagnosis, endoscopic US allows for further FNA biopsies. Histopathology of SPT reveals solid nests of poorly cohesive cells resulting in a pseudopapillary architecture. Alpha1-antitrypsin, CD56, CD10, and Vimentin are characteristically found in them. They are usually highly responsive to chemotherapy. In conclusion, pancreatic pseudopapillary tumors are rare neoplasms with malignant potential.[1831] Figure 1. MRI showing multiple hepatic lesions as well as pancreatic mass and endoscopic ultrasound illustrating heterogenous mass within the pancreatic tail with portal vein invasion.

Pancreatic pseudocyst formation is a common complication of chronic pancreatitis. Rarely, a fistula develops between the pseudocyst and the portal venous system. We present a case of a 50-year-old man who was found to have a pancreatic pseudocyst-superior mesenteric vein fistula after being evaluated for several months of abdominal pain and weight loss. The patient was treated with endoscopic stenting of the pancreatic duct along with early enteral nutrition and suppressive antibiotics, which resulted in improvement in his condition. This case report highlights clinical presentation and the complexity of treatment of this rare diagnosis.