Weber and colleagues described 31 patents who ultimately were diagnosed with LSP following pancreatic resections performed for suspected pancreatic neoplasms 6. identified until after medical treatment. Although racial variations in pancreatic duct involvement have been suggested, the underlying histopathology is the same as in PSC involving the biliary ducts. strong class=”kwd-title” Keywords: main sclerosing cholangitis, pancreatic duct, periampullary pseudomalignancy, sclerosing pancreatitis Intro Main sclerosing cholangitis (PSC) is an autoimmune disease associated with inflammatory bowel disease, specifically ulcerative colitis 1,2. It typically affects a middle-aged man with a history of ulcerative colitis. Median age of onset is definitely 40 years, and there is a 2:1 male-to-female preponderance 3. It has been estimated that approximately 70% of PSC individuals have inflammatory bowel disease but, conversely, only 5% of ulcerative colitis individuals manifest PSC. Classical laboratory findings include an extremely elevated alkaline phosphatase and a positive anti-nuclear antibody 3. Diagnosis is often made with endoscopic retrograde cholangiopan-creatography (ERCP), which characteristically shows multiple strictures of the biliary tree. Liver biopsy, demonstrating the characteristic periductal onion-skinning fibrosis, confirms the analysis. PSC is associated with multiple complications, including intrahepatic and/or extrahepatic bile duct damage, cholangiocarcinoma (estimations range from 4% to 20%), and hardly ever chronic pancreatitis 1,2. Recent studies suggest that ursodeoxycholic acid at high doses may benefit individuals with PSC and initial data from short-term randomised control tests have shown improvements in both cholangiographic looks and biochemical guidelines for PSC in individuals. Unfortunately, long-term improvement and survival possess yet to be realised 4,5 and presently, without verified effective medical treatment for the disease, the natural history is definitely progression to cirrhosis and end-stage liver disease. Transplantation is the only effective therapeutic option for these individuals 3. Recently a new entity, lymphoplasmacytic pancreatitis (LSP), has been explained in the literature. It entails a diffuse lymphoplasmacytic infiltration, interstitial fibrosis, periductal swelling and periphlebitis in Il6 the pancreas. It too masquerades like a neoplastic process and is usually diagnosed after medical extirpation 6. In this statement we describe an unusual case of a sclerosing pancreatic lesion that may be the initial presentation of main sclerosing cholangitis associated with inflammatory bowel disease. Case statement A 21-year-old male university college student from Syria presented with post-prandial epigastric pain associated with nausea and vomiting. Initial treatment with an H2 blocker and proton pump inhibitor experienced no effect. There was no history of jaundice, pancreatitis, parasitic infection or trauma. His medical history included occasional eruptions of oral lesions from herpes simplex-2 disease infection. He had had no earlier operations, nor did he smoke or drink alcohol. Oesophogastroduodenoscopy was normal. At follow-up 3 months later, the patient was mentioned to have scleral icterus and a liver biochemical profile exposing a total bilirubin of 154 em /em mol/L, an alkaline phosphatase of 871 IU/L and an AST of 385 IU/L. An abdominal ultrasound scan exposed a large irregular mass in the head of pancreas with resultant dilatation of the extrahepatic/intrahepatic biliary tree. Computed tomography (CT) of the abdomen failed to display any irregularity in the head of pancreas or dilatation of the pancreatic duct, but did reveal intrahepatic biliary tree dilatation and an abrupt cut-off of the distal common bile duct. A subsequent endoscopic retrograde cholangio-pancreaticogram (ERCP) proven similar findings (Number 1). The pancreatic duct could not become cannulated during ERCP, suggesting possible stricturing or stenosis. During that process a stent was placed, Lemildipine but it failed to reduce the jaundice. Consequently, a percutaneous trans-hepatic cholangiogram (PTC) drain was put and adequate decompression of the biliary tree was accomplished. Again, a distal bile duct stricture was visualised. The patient’s jaundice improved, but his pain, vomiting and excess weight loss (6.5 kg since onset of symptoms) persisted. Open in a separate window Number 1.? Endoscopic retrograde cholangiopancreatography showing cannulation and contrast injection into the biliary tree. Notice the dilated Lemildipine common bile duct and distal stricture in the head of the pancreas. Nine days later on the patient was transferred to our facility for re-evaluation. A trans-abdominal ultrasound check out showed a normal textured pancreas with no focal mass or adenopathy and a pancreatic duct with normal calibre. The biliary tree was mildly dilated with the Lemildipine indwelling PTC drain in place. A Lemildipine magnetic resonance cholangiopancreatography (MRCP) and abdominal CT revealed normal pancreatic and peripancreatic cells and failed to clarify presence of a stricture. Although not diagnostic of inflammatory bowel disease (IBD), colon-oscopy with mucosal biopsy exposed focal active swelling with only minimal architectural changes and suggested an IBD. Endoscopic ultrasound exposed a mass in the head of pancreas. Given that the mass was suspicious for any neoplasm, pancreatoduodenectomy was recommended. At laparotomy,.