Patient-related post-ERCP pancreatitis (PEP) risk factors between two groups of patients: Prophylactic pancreatic stent and rectal indomethacin.

Background: Pancreatitis is one of the most crucial complications following endoscopic retrograde cholangiopancreatography (ERCP). The purpose of the current study was to investigate patient-related post-ERCP pancreatitis (PEP) risk factors in two groups of patients: prophylactic pancreatic stent and rectal indomethacin. Methods: Two different prophylactic modalities were planned and complications were assessed based on the defined inclusion criteria. In this study, the patients were evaluated for the procedure and patient-related risk factors in post-ERCP pancreatitis in the recipient groups of the prophylactic pancreatic stent and rectal indomethacin. Results: Pancreatitis was confirmed in 27 of all 170 selected patients after ERCP. By univariate analysis, two variables were significant with the development of PEP. Regarding the patient-related risk factors, unique subjects with common bile duct (CBD) dilated 10mm were more exposed to an increased chance of PEP (P=0. 015); meanwhile, other factors did not correlate with the increased possibility of PEP in both groups. The only procedure-related risk factor for PEP was the deep cannulation of the pancreatic duct in both groups during the procedure with an incremental significant incidence of pancreatitis (P=0.005). Comparison of prophylactic pancreatic stent and rectal indomethacin showed no effects in term of post ERCP pancreatitis reduction. Additionally, there was no significant difference between these two strategies in the rate of PEP. Conclusion: Prophylactic pancreatic duct stents and administration of rectal indomethacin cannot have particular approaches for reducing the possible occurrence of PEP. The increase in time of deep cannulation and the presence of CBD dilation <10mm could be considered as important risk factors.

Bioburden and transmission of pathogenic bacteria through elevator channel during endoscopic retrograde cholangiopancreatography: application of multiple-locus variable-number tandem-repeat analysis for characterization of clonal strains.

OBJECTIVES: Endogenous and exogenous infection of the biliary tract could occur during endoscopic retrograde cholangiopancreatography. METHODS: Bile samples of patients with hepatobiliary diseases, and swab samples of elevator channel samples of duodenoscope and washing instruments were prepared simultaneously and cultured aerobically and anaerobically. Antimicrobial susceptibility of the most common characterized bacterial species was tested, and their genetic relatedness was analyzed by multiple locus variable number of tandem repeats method. RESULTS: Contamination with Pseudomonas aeruginosa was detected in 38.2% of the elevator channels' and 26.6% of the bile samples. Staphylococcus aureus, Enterococcus spp., Staphylococcus epidermidis, Escherichia coli, Enterobacter spp., and Clostridium perfringenes were among other bacterial isolates in the elevator channel swab samples. Highest antimicrobial resistance rate among P. aeruginosa isolates from the bile and swab samples were detected against gentamicin (100% and 73%, respectively), while the lowest one was measured to piperacillin-tazobactam (25% and 0%, respectively). Out of the 27 distinct MLVA profiles, relatedness of P. aeruginosa strains in the bile samples compared with those from the elevators was shown in three series of the samples. CONCLUSION: Identity of P. aeruginosa strains among the bile and elevator channel samples showed possibility of cross-contamination among patients even at distinct time intervals. Expert opinion: Bacterial infection is considered as main complications of ERCP. Entry of bacteria into the biliary tract via contaminated device and its related instruments and their proliferation in this tissue could cause serious infections. To prevent this side effect, reprocessing of medical equipment via standard cleaning and disinfection procedures are needed. Our results showed incompliance of methods used for endoscope cleaning and disinfection procedure. Although host risk factors, such as sphincterotomy, could increase rate of infection with different types of bacteria, their ability for formation of biofilm and spore, which could help them to resist disinfectants and washing procedures seems to be main cause of persistent colonization and transmission among different patients. New standards for disinfection compared with currently used methods and use of materials to eliminate formation of bacterial microcolonies seem to be necessary to prevent cross-contamination.

Lack of Association between Interleukin 23R (IL-23R) rs10889677 Polymorphism and Inflammatory Bowel Disease Susceptibility In an Iranian Population.

BACKGROUND: Inflammatory bowel diseases (IBDs), which include ulcerative colitis (UC) and Crohn's disease (CD), are inflammatory disorders that affect the gastrointestinal tract. A combination of inflammatory cytokines has an important role in IBD development. Genome-wide association studies have shown that polymorphisms in the interleukin-23R gene (IL-23R) increase susceptibility to IBD. The aim of this study was to investigate the IL-23R 3' UTR SNP to determine a potential association between genotype distribution and IBD. METHODS: The case group included 102 IBD patients and the control group included 107 healthy individuals. IL-23R polymorphisms rs10889677 were genotyped using PCR-RFLP analysis. RFLP results were confirmed by direct sequencing. RESULTS: The allele and genotype frequencies in patients and controls were evaluated and compared, and no significant association between this functional rs10889677 polymorphism and risk of IBD was observed (P=0.587; adjusted OR: 0.89; 95% CI: 0.597-1.339). We also found no significant association between CD (14.71%) and UC (85.29%) patients in allele or genotype levels (P>0.05). CONCLUSION: Our results suggest that the rs10889677 A>C polymorphism is not a potential prognostic marker in Iranian patients with IBD.

Epinephrine in the Prevention of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: A Preliminary Study.

BACKGROUND: Acute pancreatitis is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP). The incidence of post-ERCP pancreatitis (PEP) ranges between 15 and 20% among patients at high risk of developing PEP. The efficacy of indomethacin administration in the prevention of PEP is rather debatable. In the present randomized trial study, we evaluated whether or not the combination of indomethacin and epinephrine in comparison to the single administration of indomethacin differs in the pathogenesis and prevention of post-ERCP pancreatitis. PATIENTS AND METHODS: One hundred and ninety-two patients were randomized in a double-blinded manner into 3 groups: the epinephrine group (group A), the indomethacin group (group B), and the combined epinephrine and indomethacin group (group C). After the procedure, patients were evaluated for the PEP development. RESULTS: During the procedure, 66 patients were randomized to the epinephrine group (group A), 68 cases to the indomethacin group (group B), and 58 individuals to the indomethacin-epinephrine group (group C). The mean age of patients in the epinephrine group was 59.59 ± 15.680 years, in the indomethacin group it was 58.06 ± 17.125 years, and in the combination group it was 59.62 ± 15.369 years. In the present study, we did not observe a significant difference between the 3 groups in sex, age, pre-ERCP amylase, lipase, and patient and procedure risk factors including pancreatic duct (PD) dilation (p = 0.404), PD cannulation (p = 0.329), and difficult cannulation (p = 0.076) among others. PEP developed in 7 of the 192 individuals (3.6%), 6 PEP cases occurred in the indomethacin group and 1 in the epinephrine group (p = 0.016). Univariate analysis of risk factors for PEP in patients with and without pancreatitis revealed no significant difference between the pancreatitis group and the non-pancreatitis group. CONCLUSION: In comparison to the administration of indomethacin alone, a single application of epinephrine and the combination of epinephrine and indomethacin seem to be effective in reducing the cases of PEP. A further randomized clinical trial with a larger sample size is required to confirm the efficacy of our medication in the prevention of pancreatitis after ERCP.

Cronkhite-Canada Syndrome Associated with Metastatic Colon Cancer.

Cronkhite-Canada syndrome is characterized by gastrointestinal and ectodermal manifestations. In this paper, we describe a 64-year-old Iranian male, presenting with Cronkhite-Canada syndrome with metastatic colon cancer. The patient was suffering from hair loss, which occurred on the scalp at first and then, during 5 months, extended to the whole body. After that, his sense of taste was impaired, and 2 months later, gastrointestinal symptoms gradually started, with weight loss of 20 kg over 2 months with an initial weight of 100 kg. Finally, he was admitted to our center 10 months after the onset of symptoms. On skin examination, generalized hair loss and hyperpigmentation and dysmorphic nail changes were observed. Multiple polyps within the colon and sigmoid were observed on colonoscopy. According to biopsies, a serrated adenoma and an invasive adenocarcinoma were reported in the ascending colon and sigmoid, respectively. Other polyps were pseudopolyps, and their characteristics were not significant. Computed tomography of the lungs and abdomen showed multiple adenopathies. On biopsy, metastatic adenocarcinoma was reported. The patient underwent chemotherapy with FOLFIRI and ERBITUX. Finally, after 5 courses of chemotherapy, his regimen was changed to FOLFOX and Avastin because of evidence of progression on computed tomography. The etiology of Cronkhite-Canada syndrome is currently unknown, and the optimal therapy has not been reported so far. This syndrome has many complications; the major of them is malignancy, and the prognosis is poor with a mortality rate of 50%. Therefore, annual monitoring is necessary in these patients.

Cholangitis: Diagnosis, Treatment and Prognosis.

Cholangitis is a serious life-threatening situation affecting the hepatobiliary system. This review provides an update regarding the clinical and pathological features of various forms of cholangitis. A comprehensive search was performed in the PubMed, Scopus, and Web of Knowledge databases. It was found that the etiology and pathogenesis of cholangitis are heterogeneous. Cholangitis can be categorized as primary sclerosing (PSC), secondary (acute) cholangitis, and a recently characterized form, known as IgG4-associated cholangitis (IAC). Roles of genetic and acquired factors have been noted in development of various forms of cholangitis. PSC commonly follows a chronic and progressive course that may terminate in hepatobiliary neoplasms. In particular, PSC commonly has been associated with inflammatory bowel disease. Bacterial infections are known as the most common cause for AC. On the other hand, IAC has been commonly encountered along with pancreatitis. Imaging evaluation of the hepatobiliary system has emerged as a crucial tool in the management of cholangitis. Endoscopic retrograde cholangiography, magnetic resonance cholangiopancreatography and endoscopic ultrasonography comprise three of the modalities that are frequently exploited as both diagnostic and therapeutic tools. Biliary drainage procedures using these methods is necessary for controlling the progression of cholangitis. Promising results have been reported for the role of antibiotic treatment in management of AC and PSC; however, immunosuppressive drugs have also rendered clinical responses in IAC. With respect to the high rate of complications, surgical interventions in patients with cholangitis are generally restricted to those patients in whom other therapeutic approaches have failed.

Primary pancreatic lymphoma: what we need to know.

Hodgkin's lymphoma is a group of malignant lymphoid which involve various organs including gastrointestinal tract. Stomach and small intestine are commonly involved more; however, pancreas can be primarily involved as well. The secondary involvement of pancreas caused by Hodgkin's lymphoma is more prevalent than the primarily involvement (1 .25-2.2% vs. <1%). Primary pancreatic lymphomas (PPLs) consist of 1-2% of all lymphoma outside nods. The symptoms and findings of PPL imaging can be akin to that of pancreas adenocarcinoma and differentiating them is difficult without examining the tissue sample. The prognosis and treatment of PPL are different from those of adenocarcinoma and due to the superior prognosis of PPL compared to pancreas adenocarcinoma, the proper diagnosis of the disease is important.

Pancreatic Squamous Cell Carcinoma.

Pancreatic squamous cell carcinoma (SCC) is a rare event. Here, we present a 56-year-old man with pancreatic SCC. Imaging methods demonstrated a hypodense mass at the head and trunk of the pancreas. Also, some lymphadenopathy has been seen around the pancreas and para-aorta. The mass created pressure and encasement on the celiac trunk, portal vein, and arteries of the liver and spleen. Endoscopic ultrasound showed a mass lesion of 45-37 mm (mixed echoic) at the trunk of the pancreas. Histological examination of the endoscopic ultrasound-guided fine needle aspiration specimen confirmed the diagnosis of SCC. The disease is highly aggressive, most often locally advanced or metastatic at diagnosis, and poorly responsive to treatment. It also has generally poor survival rates.

TGF-ß1 polymorphisms -509 C>T and +915 G>C and risk of pancreatic cancer.

BACKGROUND: Ninety percent of pancreatic cancer patients have less than 5-year overall survival and approximately 50% of cases were diagnosed with metastasis in the time of admission. Previous evidences have demonstrated the strong association between TGF-ß1 variations and cancer susceptibility so far. METHODS: A total of 78 patients with pancreatic cancer and 94 healthy controls were enrolled in this case- control study between 2007 and 2012. Genomic DNA was isolated from peripheral blood samples according to phenol chloroform extraction. The genotypes of TGF-ß1 rs rs1800469 and rs1800471 were determined using the polymerase chain reaction-restriction fragment length polymorphism method. RESULTS: The mean age of cases and the control group were 64.50 ± 13.718 and 40.12 ± 16.001, respectively. For polymorphism -509 C>T, the frequency of TT genotype were 31 (33.0), CT, 47(50) and CC, 16 (17) in control and 19 (24.4), 45 (57.7) and 14 (17.9) in cases respectively. In position +915 G>C, the frequency of GG genotype was 84 (89.4) and GC, 10 (10.6) in control and 71 (91.0) and 7 (9) in cases, respectively. We did not observe any significant differences in the genotype and allele frequencies of the TGF-ß1-509 C>T (rs1800469) and codon +915 G>C (rs1800471) between the two study groups (P>0.05). CONCLUSION: we found that TGF-ß1 gene polymorphisms rs1800469 and rs1800471 might not play a role in pancreatic cancer susceptibility in Iranian population.

The frequency of bacterial contamination and diversity of drug resistance patterns in devices and staff of endoscopy and colonoscopy units.

Background: This study aimed at analyzing microbial contamination in medical equipment, environment, and staff of a gastroenterology unit. Methods: Samples of gastrointestinal imaging devices, the environment, and staff were collected using standard swab-rinse technique and biochemical or molecular characteristics of the isolates, their susceptibility to antibiotics, and similarity of the resistance patterns were investigated. Results: Out of 107 samples, bacterial contamination was detected in the hands of staff (54.1%), imaging devices (56.7%), and in the environment (54.5%). While Pseudomonas spp. were detected only in the imaging devices (13.5%), Bacillus spp. (32.4% and 31.5%), Enterococcus spp. (14.3% and 5.9%), Clostridium difficile (10.8% and 10.5%), and Staphylococcus epidermidis (5.4% and 15.9%) were orderly the most common isolates from samples of the imaging devices and the environment. Nearly, 40% of P. aeruginosa strains were resistant to cefepime, while resistance to cephalosporins and ß-lactamase inhibitor was detected in 33% and 75% of S. aureus strains, respectively. Homology of resistance patterns was detected between the imaging devices and hands of the staff. Conclusion: Our results proposed biofilm and spore forming bacteria as main contaminants of imaging devices in this hospital. Homology of the resistance patterns proposed involvement of staff in contamination of the equipment.

ATP binding cassette and cholecystokinin A receptor genetic variations in gallstone susceptibility.

AIM: It was aimed to assess the association of four polymorphisms and relative haplotypes in the ATP binding cassettes and cholecystokinin A receptor (rs6720173, rs11887534, rs4148217, rs1800857) with the risk of gallstone. BACKGROUND: Gallstone is a multifactorial disease. Besides high penetrance genes, low or moderate penetrance polymorphisms may increase susceptibility to gallstone. METHODS: 200 gallstone patients and 251 healthy controls were analyzed in a case-control association model. Genotyping was carried out by restriction fragment length polymorphism. Randomly 10% of samples underwent for direct sequencing to confirm results. RESULTS: Heterozygote variant of rs11887534 demonstrated protective effect on the risk of gallstone susceptibility in males (P=0.013; OR=0.125; CI95%=0.048-0.325). In contrast, C/C genotype associated with gallstone susceptibility in females (P=0.004; OR=5.555 CI95%=1.975-10.632). Moreover, rs1800857 showed association only in females (P=0.019; OR=0.283; CI95%=0.099-0.811). Haplotype analysis for rs1800857 showed GC, CC and CA association with gallstone. CONCLUSION: The most imperative polymorphisms of contributing genes to gallstone were analyzed in this study and rs11887534 and rs1800857 appeared to be associated with gallstone, which is expected to be further verified in a larger cohort in the future.

Diagnosis of Malignant Biliary Strictures: Conventional or Negative Pressure Brush Cytology?

Background/Objective: The aim of this study was to perform a comparative evaluation of the yields of conventional brush cytology and brush cytology with negative pressure in the diagnosis of malignant biliary strictures. Methods: A total of 132 consecutive patients undergoing endoscopic were identified. Of these, 88.0 had brush cytology after ERCP and 44 were Brush cytology with negative pressure. Retrograde cholangiopancreatography (ERCP) including brush cytology and brush cytology with negative pressure in patients with biliary strictures between 2012-2015. Endoscopic retrograde cholangiography was performed with a standard videoduodenoscope Olympus TFJ 160-R (Olympus, Hamburg, Germany) and brush cytology with a Cook medical Double Lumen Biliary BrushTM (Cytology). Means and standard frequencies were used to calculate variables. Results: Positive results for malignancy were obtained in 22 of 88 patients (25%) by brush cytology and 31 of 44 patients (70.4 %) by brush cytology with negative pressure. Conclusions: Sensitivity of cytology sampling could be maximized by negative pressure during ERCP.

Comparing the Roles of EUS, ERCP and MRCP in Idiopathic Acute Recurrent Pancreatitis.

Acute recurrent pancreatitis (ARP) is defined as more than two attacks of acute pancreatitis with complete or almost complete resolution of symptoms and signs of pancreatitis between episodes. The initial evaluation fails to detect the cause of ARP in 10%-30% of patients, whose condition is classified as idiopathic ARP. Endoscopic ultrasound (EUS) has gained increasing attention as a useful imaging modality for the pancreas and the extrahepatic biliary tree. The close proximity of the pancreas to the digestive tract allows EUS to obtain detailed images of this organ. This review aims to record pancreaticobiliary endoscopic ultrasound (EUS) and other imaging modalities in the clinical management of patients with idiopathic ARP.

Diagnostic potency of EUS-guided FNA for the evaluation of pancreatic mass lesions.

BACKGROUND AND OBJECTIVES: Diagnosis of pancreatic lesions remains a clinical challenge. This study aimed to evaluate the diagnostic accuracy of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in pancreatic mass lesions. PATIENTS AND METHODS: Clinical data, laboratory tests, and cytopathological and imaging reports were collected from 185 pancreatic EUS cases performed from March 2010 to January 2014. The final diagnosis was based on surgical findings, EUS-FNA or computed tomography (CT)-guided biopsy. RESULTS: A total of 100 pancreatic FNAs were obtained by EUS. Most positive diagnoses of malignancy were pancreatic adenocarcinomas (n = 61). The site of pancreatic adenocarcinoma was the head in 50 (82.0%), body in seven (11.5%), and tail in four (6.5%). The sensitivity, specifi city, and positive and negative predictive values of EUS-FNA for diagnosing adenocarcinoma were 80.3%, 92.3%, 94.2%, and 75.0%, respectively. DISCUSSION: We concluded that EUS-FNA of pancreatic lesion accurately diagnoses pancreatic adenocarcinoma and should be considered for the standard management of pancreatic adenocarcinoma.

A Man with Pancreatic Head Mass Lesion on Endoscopic Ultrasound and Granuloma on Cytopathology.

Primary pancreatic lymphoma is an unlikely malignancy accounting for less than 0.5% of pancreatic tumors. Clinical presentation is often nonspecific and may be clinically misdiagnosed as pancreatic adenocarcinoma. Here we present an Iranian case of primary pancreatic lymphoma in a 47-year-old male suffering from jaundice and 20% weight loss. Endoscopic ultrasound revealed a mixed echoic mass lesion at the head of pancreas. The patient underwent endoscopic ultrasound-guided fine needle aspiration of solid pancreatic mass and histopathologic diagnosis revealed granuloma. Computed tomography-guided core needle biopsy was performed and eventually histological examination showed granuloma that was coherent with the diagnosis of primary pancreatic lymphoma. Primary pancreatic lymphoma is a rare entity presenting with nonspecific symptoms, laboratory and radiological findings. Computed tomography results in combination with clinical and radiological studies generally provide guidance for appropriate investigation.

Secondary Sclerosing Cholangitis and Hodgkin's Lymphoma.

CONTEXT: Liver damage is relatively common in patients affected by HL, but paraneoplastic cholestasis is an uncommon presenting symptom in HL. CASE REPORT: We report the case of a 38-year-old man who came to our hospital with jaundice, pruritis, nausea, vomiting, weight loss, and recurrent episodes of fever without any hepatosplenomegaly or lymphadenopathy. Laboratory findings showed abnormal liver functioning with mixed hepatocellular and cholestatic patterns. Sonographic evaluation of the biliary tract was normal. We ruled out viral infections, autoimmune process, and hemochromatosis. The patient was put on ursobile and NAC (N-acetyl-systeine) and prednisolone treatment. In magnetic resonance cholangiopancreatography examination, there were multiple strictures in the intrahepatic and extrahepatic bile ducts with mild dilatation. Histologic finding of liver biopsy was compatible with sclerosing cholangitis or drug-induced cholestasis. General condition and laboratory examination results of the patient became better, but we found lymph-adenopathy on monthly follow-up examination. Histological finding of the lymph node was compatible with HL. CONCLUSION: This report emphasizes that HL can be presented with different paraneoplastic symptoms and that one of them is secondary sclerosing cholangitis. It has better prognosis than vanishing bile duct syndrome, and perhaps steroid treatment can be suggested.

Is ESR Important for Predicting Post-ERCP Pancreatitis?

BACKGROUND: Pancreatitis remains the most common complication of endoscopic retrograde cholangiopancreatography (ERCP), resulting in substantial morbidity and occasional mortality. There are notable controversies and conflicting reports about risk factors of post-ERCP pancreatitis (PEP). AIM: To evaluate the potential risk factors for PEP at a referral tertiary center, as a sample of the Iranian population. MATERIALS AND METHODS: Baseline characteristics and clinical as well as paraclinical information of 780 patients undergoing diagnostic and therapeutic ERCP at Taleghani hospital in Tehran between 2008 and 2012 were reviewed. Data were collected prior to the ERCP, at the time of the procedure, and 24-72 hours after discharge. PEP was diagnosed according to consensus criteria. RESULTS: Of the 780 patients who underwent diagnostic ERCP, pancreatitis developed in 26 patients (3.3%). In the multivariable risk model, significant risk factors with adjusted odds ratios (ORs) were age <65 years (OR = 10.647, P = 0.023) and erythrocyte sedimentation rate (ESR) >30 (OR = 6.414, P < 0.001). Female gender, history of recurrent pancreatitis, pre-ERCP hyperamylasemia, and difficult or failed cannulation could not predict PEP. There was no significant difference in the rate of PEP in wire-guided cannulation versus biliary cannulation using a sphincterotome and contrast injection as the conventional method. CONCLUSIONS: Performing ERCP may be safer in the elderly. Patients with high ESR may be at greater risk of PEP, which warrants close observation of these patients for signs of pancreatitis after ERCP.

Biliary stent migration to hepatic duct-case report of a late complication.

Endoscopic retrieval of proximally migrated biliary plastic stents may be technically challenging and sometimes unsuccessful. Here we report the case of a 59-year-old woman with a migrated biliary stent in the right hepatic duct, which was diagnosed after the patient presented with cholangitis. The patient presented with constant abdominal pain in the right upper quadrant lasting for two days, along with nausea and bilious vomiting. The stent was retrieved by a polypectomy snare after failure of biliary basket and forceps. We performed a novel procedure for extraction of a migrated plastic stent, by using a polypectomy snare.

Finding of biliary fascioliasis by endoscopic ultrasonography in a patient with eosinophilic liver abscess.

Fascioliasis is an endemic zoonotic disease in Iran. It occurs mainly in sheep-rearing areas of temperate climates, but sporadic cases have been reported from many other parts of the world. The usual definitive host is the sheep. Humans are accidental hosts in the life cycle of Fasciola. Typical symptoms may be associated with fascioliasis, but in some cases diagnosis and treatment may be preceded by a long period of abdominal pain and vague gastrointestinal symptoms. We report a case with epigastric and upper quadrant abdominal pain for the last 6 months, with imaging suggesting liver abscess and normal biliary ducts. The patient had no eosinophilia with negative stool examinations, so she was initially treated with antibiotics for liver abscess. Her clinical condition as well as follow-up imagings showed appropriate response after antibiotic therapy. Finally, endoscopic ultrasonography revealed Fasciola hepatica, which was then extracted with endoscopic retrograde cholangiopancreatography.

The role of endoscopic ultrasound in primary pancreatic lymphoma presented with acute pancreatitis: a case report.

CONTEXT: Primary pancreatic lymphoma (PPL) is rare but manageable malignant tumor of the pancreas which may be confused with pancreatic adenocarcinoma. CASE REPORT: We report a 38 year-old smoker man with IVDA and history of B (inactive carrier), C (Ia genotype) hepatitis and negative for HIV admitted to our hospital because of nausea, vomiting, epigastric and RUQ pain as a result of long period of alcohol consumption. Due to high amount of amylase (480 U/L) and lipase (326 U/L) Pancreatitis was diagnosed. Four days after admission CT was done that showed enhancement a large tumor of the head of the pancreas. Endoscopic ultrasound (EU) revealed diffusely enlarged of pancreas. There was a mixed echoic mass lesion 37-50 mm at the head of pancreas (R/O walled off necrosis) with adhesion to portal vein and SMV. On the other hand the CBD was 9 mm. Abdominal MRI and MRCP for patient was done. The intra-hepatic bile ducts, main hepatic ducts, CHD and CBD were mildly dilated and displaced to the right side by a large lobulated mass (160×112×130 mm) of pancreatic head with low signal intensity on T1W images and high intensity on T2W images. we did EUS-FNA and there was a mixed echotic lesion (38-40 mm) adhered to head of pancreas with invasion to portal vein, SMA and SMV. The diagnosis of pancreatic lymphoma was established by immunohistochemical study and the assessment of the neoplastic cells revealed B cell lymphoma phenotypes. CONCLUSION: Herein we present an interesting 38 year- old man with pancreas head tumor. Primary pancreatic lymphoma is almost never suspected clinically. It is usually diagnosed by imaging and histological methods.