538 Gut and Liver, Vol. 5, No. 4, December 2011 inoculum is used. Furthermore, an antimycobacterial effect of pancreatic extracts, purified lipases, and deoxyribonucleases has been reported.7 The main clinical manifestations of pancreatic TB include epi- gastric pain (64%), fever (53%), weight loss (40%), and anorexia (36%).8 Contrast-enhanced CT may demonstrate hypodense and/ or multiloculated masses, diffuse enlargement of the pancreas, and stenosis of the pancreatic duct. These features are nonspe- cific and can resemble pancreatic carcinoma, pancreatitis, and lymphoma.9 The diagnosis of pancreatic TB should be considered when the following are observed: 1) young patients with a personal history of TB or exposure to TB; 2) patients with active TB; 3) congenital or acquired immune deficiency; 4) positive tubercu- lin test, elevated erythrocyte sedimentation rate, or abnormal serum globulin; 5) ultrasound and/or CT demonstration of focal hypoechoic or hypodense masses with ring enhancement or in- ternal separation. When pancreatic TB is suspected, ultrasound or CT-guided FNAB may help determine the diagnosis. Even if the initial mi- crobiological results are negative, conventional techniques and polymerase chain reaction should be performed to avoid unnec- essary laparotomy.10 Once the diagnosis of pancreatic TB is con- firmed, standard chemotherapy has been shown to have good curative effect.11 Our hospital did not have the needle systems for FNAB; consequently, ultrasound and/or CT-guided FNAB was not undertaken preoperatively. This case represents a rare presentation of a patient with mul- tiple pancreatic masses. Gouya et al.12 reported only 2 patients out of a group of 30 patients with insulinomas had more than one insulinoma. In 1998, Klein et al.13 retrospectively analyzed 66 patients with metastases to the pancreas and identified mul- tiple tumors in 11 patients. In our case, the definitive diagnosis was made by an intraoperative FNAB. The sensitivity, specific- ity, false-positive rate, and complication rate for intraoperative FNAB were 93%, 100%, 0%, and 0%, respectively.14 The biopsy method can be an important tool utilized to avoid unnecessary resection, and to reduce the morbidity and mortality that ac- company inappropriate surgical interventions. In conclusion, pancreatic TB should be considered in the differential diagnosis of pancreatic masses, especially in areas where TB is prevalent. To avoid unnecessary laparotomy or resection, histopathological and microbiological evaluations should be performed, preferably before (or during) the opera- tion. If multiple masses are present, biopsies must be taken from all the masses in order to direct subsequent therapy. CONFLICTS OF INTEREST No potential conflict of interest relevant to this article was reported. REFERENCES 1. Frieden TR, Sterling TR, Munsiff SS, Watt CJ, Dye C. Tuberculosis. Lancet 2003;362:887-899. 2. Bhansali SK. Abdominal tuberculosis. Experiences with 300 cases. Am J Gastroenterol 1977;67:324-337. 3. Auerbach O. Acute generalized miliary tuberculosis. Am J Pathol 1944;20:121-136. 4. Paraf A, Ménager C, Texier J. Tuberculosis of the pancreas and tuberculosis of the lymph nodes of the upper region of the abdo- men. Rev Med Chir Mal Foie 1966;41:101-126. 5. Stambler JB, Klibaner MI, Bliss CM, LaMont JT. Tuberculous ab- scess of the pancreas. Gastroenterology 1982;83:922-925. 6. Stock KP, Riemann JF, Stadler W, Rösch W. Tuberculosis of the pancreas. Endoscopy 1981;13:178-180. 7. Knowles KF, Saltman D, Robson HG, Lalonde R. Tuberculous pan- creatitis. Tubercle 1990;71:65-68. 8. Xia F, Poon RT, Wang SG, Bie P, Huang XQ, Dong JH. Tuber- culosis of pancreas and peripancreatic lymph nodes in immuno- competent patients: experience from China. World J Gastroenterol 2003;9:1361-1364. 9. De Backer AI, Mortelé KJ, Bomans P, De Keulenaer BL, Vanschou- broeck IJ, Kockx MM. Tuberculosis of the pancreas: MRI features. AJR Am J Roentgenol 2005;184:50-54. 10. Riaz AA, Singh A, Robshaw P, Isla AM. Tuberculosis of the pancreas diagnosed with needle aspiration. Scand J Infect Dis 2002;34:303-304. 11. Veerabadran P, Sasnur P, Subramanian S, Marappagounder S. Pancreatic tuberculosis-abdominal tuberculosis presenting as pan- creatic abscesses and colonic perforation. World J Gastroenterol 2007;13:478-479. 12. Gouya H, Vignaux O, Augui J, et al. CT, endoscopic sonography, and a combined protocol for preoperative evaluation of pancreatic insulinomas. AJR Am J Roentgenol 2003;181:987-992. 13. Klein KA, Stephens DH, Welch TJ. CT characteristics of metastatic disease of the pancreas. Radiographics 1998;18:369-378. 14. Schadt ME, Kline TS, Neal HS, Scoma RS, Naryshkin S. Intraop- erative pancreatic fine needle aspiration biopsy. Results in 166 patients. Am Surg 1991;57:73-75.