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cohol abuse or biliary obstruction [1], however, it can also result from pancreat− ic cancer [2]. The association between acute pancreatitis and pancreatic cancer has been reported [3], and the majority of these cases were initially misinterpret− ed as idiopathic pancreatitis. This is the first report describing a case of pancreatic cancer in the setting of biliary stones complicated by recurrent acute pancrea− titis. A 79−year−old woman presented with in− termittent upper abdominal pain for 10 months. She had experienced an episode of acute pancreatitis 10 months previous− ly, and gallstones were detected by trans− abdominal ultrasound; but she declined laparoscopic cholecystectomy. Seven months later, the abdominal pain re− curred. Based on the symptoms, signi− ficantly elevated serum amylase, and computed tomography (CT) findings (l" Fig. 1), acute pancreatitis was diag− nosed. Magnetic resonance imaging (MRI) revealed both common bile duct (CBD) stones (l" Fig. 2 a) and gallstones (l" Fig. 2 b). She underwent laparoscopic cholecystectomy uneventfully. She was later referred for CBD stone removal. Her physical examination and laboratory findings were unremarkable. During en− doscopic retrograde cholangiopan− creatography, the papilla was examined and no obvious abnormality was found. Cholangiogram detected multiple filling defects, suggesting CBD stones. These stones were extracted completely (l" Fig. 3). However, the patient complained of re− current severe epigastric pain afterwards. An abdominal plain radiograph did not suggest duodenal perforation, and serum amylase was unremarkable. We proceed− ed with a CT scan, and it showed a pan− creatic head hypodense mass (l" Fig. 4 a). Subsequent endoscopic ultrasound−guid− ed fine−needle aspiration revealed pan− creatic adenocarcinoma (l" Fig. 4 b). In the exudative phase of acute pancreati− tis, the acute fluid collection and non−en− hanced pancreatic parenchyma may ob− scure the appearance of pancreatic can− cer; therefore, the initial mass could have been missed during initial CT due to the acute inflammatory changes. Therefore, when pancreatic cancer is suspected, CT scanning during the pancreatic parenchy− mal phase is quite important to detect the malignant lesions [4].

Occult pancreatic head cancer in the setting of gallstone and common bile duct stones complicated by acute pancreatitis