Partial annular pancreas in a 12-year-old girl

Djordje  Savić; Dragan  Prokić; Blagoje  Grujić; Miroslav  Vukadin; Vesna  Milojković Marinović; Petar  Rašić; Maja Miličković

doi:10.2298/VSP200512042S

Djordje Savić Mother and Child Health Care Institute of Serbia “Dr. Vukan Čupić”¬, Belgrade, Serbia; University of Belgrade, Faculty of Medicine, Belgrade, Serbia
Dragan Prokić Mother and Child Health Care Institute of Serbia “Dr. Vukan Čupić”¬, Belgrade, Serbia; University of Belgrade, Faculty of Medicine, Belgrade, Serbia
Blagoje Grujić Mother and Child Health Care Institute of Serbia “Dr. Vukan Čupić”¬, Belgrade, Serbia; University of Belgrade, Faculty of Medicine, Belgrade, Serbia
Miroslav Vukadin Mother and Child Health Care Institute of Serbia “Dr. Vukan Čupić”¬, Belgrade, Serbia
Vesna Milojković Marinović Mother and Child Health Care Institute of Serbia “Dr. Vukan Čupić”¬, Belgrade, Serbia; University of Belgrade, Faculty of Medicine, Belgrade, Serbia
Petar Rašić Mother and Child Health Care Institute of Serbia “Dr. Vukan Čupić”¬, Belgrade, Serbia
Maja Miličković Mother and Child Health Care Institute of Serbia “Dr. Vukan Čupić”¬, Belgrade, Serbia; University of Belgrade, Faculty of Medicine, Belgrade, Serbia

DOI: https://doi.org/10.2298/VSP200512042S

Keywords: annular pancreas;, child;, diagnosis;, endoscopy, digestive system;, tomography, x-ray computed.

Abstract

Introduction. Annular pancreas is a rare congenital anomaly in which a band of the pancreatic tissue, in continuity with the pancreatic head, completely or incompletely surrounds the descending part of the duodenum. An abnormal pancreatic development can cause complete annular pancreas, partial annular pancreas, and pancreas divisum. Complete annular pancreas is diagnosed in newborns, while the diagnosis of the partial annular pancreas is more frequently established in adults. The most reliable diagnostic methods are computed tomography and magnetic resonance cholangiopancreatography. The anomaly is treated surgically, using bypass procedures. Case report. A 12-year-old girl presented malnourished, with occasional feeding problems, vomiting, heartburn, and pain from infancy. The upper gastrointestinal series showed an extremely dilated stomach, the first and the second part of the duodenum. An endoscopic exam revealed the dilated stomach, pylorus, and the first and the second part of the duodenum with retained contrast, while the entrance of the endoscope into the third part of the duodenum was not possible. Computed tomography showed pancreatic tissue encircling the second part of the duodenum and the characteristic "crocodile jaw" sign. Roux-en-Y duodenojejunostomy was performed as a bypass procedure. Conclusion. The complete annular pancreas is a well-known and easily diagnosed anomaly in newborns. The partial annular pancreas is often poorly recognized, especially in patients who do not present with marked duodenal obstruction. Unrevealed, it causes chronic problems in food intake, with possible serious complications. Although a very rare condition in the pediatric population, partial annular pancreas should be taken into consideration in unclear cases of chronic poor oral food intake and vomiting.

References

Mittal S, Jindal G, Mittal A, Singal R, Singal S. Partial annular pancreas. Proc (Bayl Univ Med Cent) 2016; 29(4): 402–3.

Singh SK, Agrawal DK, Suganita, Singh GN, Singh AK. Annular pancreas causing duodenal obstruction: a case report. J Evolu-tion Med Dent Sci 2016; 5(5): 296‒300.

Glazer G, Margulis A. Annular pancreas: etiology and diagnosis using endoscopic retrograde cholangiopancreatography. Radi-ology 1979; 133(2): 303‒6.

Dowsett JF, Rode J, Russell RC. Annular pancreas: a clinical, endoscopic, and immunohistochemical study. Gut 1989; 30(1): 130–5.

Sandrasegaran K, Patel A, Fogel EL, Zyromski NJ, Pitt HA. An-nular pancreas in adults. AJR Am J Roentgenol 2009; 193(2): 455‒60.

Baggott BB, Long WB. Annular pancreas as a cause of extrahe-patic biliary obstruction. Am J Gastroenterol 1991; 86(2): 224‒6.

Zyromski NJ, Sandoval JA, Pitt HA, Ladd AP, Fogel EL, Mattar WE, Sandrasegaran K, et al. Annular pancreas: dramatic differ-ences between children and adults. J Am Coll Surg 2008; 206(5): 1019‒25; discussion 1025‒7.

Urayama S, Kozarek R, Ball T, Brandabur J, Traverso L, Ryan J, et al. Presentation and treatment of annular pancreas in an adult population. Am J Gastroenterol 1995; 90(6): 995‒9.

Chen YC, Yeh CN, Tseng JH. Symptomatic adult annular pan-creas. J Clin Gastroenterol 2003; 36(5): 446‒50.

Kandpal H, Bhatia V, Garg P, Sharma R. Annular pancreas in an adult patient: diagnosis with endoscopic ultrasonography and magnetic resonance cholangiopancreatography. Singapore Med J 2009; 50(1): e29‒31.

Noor R, Mohamad Z, Farhan S, Nor T. Annular pancreas causing duodenal obstruction in two consecutive sisters. Saudi Surg J 2017; 5(2): 87‒8.

Udgirkar S, Chandnani S, Zanwar V, Surude R, Contarctor Q, Ra-thi P. Duodenal and Bile Duct Narrowing Due to Partial An-nular Pancreas: A Rare Association. J Assoc Physicians India 2018; 66(6): 92‒4.

Lin SZ. Annular pancreas. Etiology, classification and diagnos-tic imaging. Chin Med J (Engl) 1989; 102(5): 368‒72.

Jadvar H, Mindelzun RE. Annular pancreas in adults: imaging features in seven patients. Abdom Imaging 1999; 24(2): 174‒7.

Wani AA, Maqsood S, Lala P, Wani S. Annular pancreas in adults: a report of two cases and review of literature. JOP 2013; 14(3): 277‒9.

Mittal P, Gupta K, Mittal A, Gupta R. Imaging findings in in-complete annular pancreas in adults with crocodile jaw ap-pearance: report of two cases. Int J Health Allied Sci 2016; 5(4): 278–80.

Inamoto K, Ishikawa Y, Itoh N. CT demonstration of annular pancreas: case report. Gastrointest Radiol 1983; 8(2): 143–4.

Johnston DW. Annular pancreas: a new classification and clini-cal observations. Can J Surg 1978; 21(3): 241‒4.

Anish N, Adarash M, Kumar VV, Prabkharan M. Incomplete annular pancreas presenting with gastric outlet obstruction and pancreatitis-a case report. Int J Sci Res 2019; 8(9): doi: 10.36106/ijsr.

Hill S, Koontz CS, Langness SM, Wulkan ML. Laparoscopic versus open repair of congenital duodenal obstruction in in-fants. J Laparoendosc Adv Surg Tech 2011; 21(10): 961–3.

Ignjatović D, Cuk V, Misović S. War, traffic and iatrogenic inju-ries of D3 duodenal segment. Vojnosanit Pregl 2005; 62(1): 69‒72. (Serbian)