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| CASE REPORT |
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| Year : 1991 | Volume
: 37
| Issue : 1 | Page : 52-5 |
Annular pancreas in adults (2 case reports).
Machado N, Rajan N, Rao BH
Department of Surgery, Kasturba Medical College and Hospital, Manipal, Karnataka.
Correspondence Address:
Department of Surgery, Kasturba Medical College and Hospital, Manipal, Karnataka.
Two cases of annular pancreas in adults are being reported. In the first case, a middle aged lady presented with duodenal obstruction and gastric ulcer. Anterior H. S. V. with posterior truncal vagotomy and isoperistaltic duodeno-jejunostomy relieved her symptoms. In the second case, a young girl presented with duodenal obstruction, severe wasting and gross dehydration. She had an uneventful recovery following a duodeno-jejunostomy.
How to cite this article:
Machado N, Rajan N, Rao B H. Annular pancreas in adults (2 case reports). J Postgrad Med 1991;37:52 |
Annular pancreas results due to the failure of the ventral anlage of the pancreas to rotate with the duodenum, an event that normally occurs in the 7th week of gestation. This failure to rotate results in envelopment of the second part of the duodenum. Though originally described by Tiedmann in 1818, it was Esker in 1862 who first suggested this name1. Almost half the children and fifteen per cent of the adults with annular pancreas have associated duodenal stenosis. About one-third of the patients present with peptic ulcer of the stomach or duodenum (probably due to prolonged antral stasis). Two cases of annular pancreas with these complications are being reported.
A 45-year-old female patient was admitted on 17-8-1997 with a history of vomiting of 2 years' duration. The vomit was neither blood-stained nor bile-stained. These episodes occurred some time after food intake, usually in the evening. She complained of a feeling of fullness on taking food. There was a history of loss of appetite but no history of abdominal pain. No other major medical or surgical illness was reported.
General examination revealed no abnormality except for mild dehydration. Her vital parameters were within normal limits. Abdominal examination revealed no abnormality except for visible gastric peristalsis.
Haemogram and urine examination were within normal limits. Plain X-ray abdomen showed a gas shadow in the duodenal bulb. Gastroscopy demonstrated a small benign ulcer at the angle of incisura. The first part of the duodenum was found to be dilated and the second part of the duodenum narrowed, but the scope could be passed beyond the constriction.
An exploratory laparotomy was undertaken on August 22 1987, which showed scarring of the lesser curvature due to chronic gastric ulcer and an annular pancreas constricting the duodenum resulting in proximal duodenal dilatation. The rest of the pancreas was normal. An anterior H.S.V. and posterior truncal vagotomy with isoperistaltic duodeno-jejunostomy was performed, using inner continuous catgut and outer interrupted sero-muscular layer with 3/0 atraumatic silk. Post-operative period was uneventful and the patient was discharged on the 9th post-operative day. Patient has remained symptom-free todate.
The second case was a seventeen-year-old female patient, presented on 2-2-1988 with a history of bouts of non-bilious vomiting of six weeks' duration. There was no significant past history. On examination, the patient was found to be emaciated, grossly dehydrated and weighed 20 kgs. Abdominal examination revealed visible gastric peristalsis. Gastroscopy revealed grossly dilated first part of duodenum and narrowed second part with normal mucosa. Barium study confirmed the above findings (See [Figure - 1]). The patient was built up for exploration. Laparotomy revealed grossly dilated duodenum compressed by an annular pancreas. (See [Figure - 2]). A duodeno-jejunostomy was done in two layers, as in the previous case. Patient was discharged on the 9th post-operative day following an uneventful recovery.
The normal pancreas develops from three outgrowths of the primitive duodenum, two ventral and one dorsal. The ventral buds fuse early and then rotate with the gut, passing behind the duodenum from right to left and finally fusing with the dorsal outgrowth. The ventral component forms the inferior part of the head of the pancreas and uncinate process and its duct becomes the final channel of the main pancreatic duct. The remainder of gland and duct are derived from the dorsal outgrowth. To explain the development of annular pancreas, following theories have been put forward; 1 (i) persistence of left ventral anlage; (ii) adherence of the ventral anlage to the anterior duodenal wall preventing its rotation with the gut; (iii) fusion of the ventral and dorsal buds anteriorly before rotation has begun; (iv) ectopic pancreatic tissue developing in the region of the duodenum ‘per se' and later fusing with normal pancreas.
Annular pancreas is one of the rare causes of duodenal obstruction in adults. The age of onset of symptoms depends upon the severity of constriction and associated stenosis or atresia of the duodenum if any15. Cases usually fall in two age groups - infantile (from birth to 4 years) and adults (from 17 onwards). When it occurs in infants, the mothers may have polyhydramnios. Other associated congenital anomalies are mongolism, oesophageal atresia with tracheo-oesophageal fistula, imperforate anus, duodenal atresia, malrotation of colon, cryptorchidism and Meckel's Divrticulum5. In adults complications like duodenal obstruction and peptic ulcer of the stomach or duodenum1, are known to occur, which were seen in our patients. The other complications that can occur are acute or chronic pancreatitis4 of the annulus itself and rarely biliary obstruction. On examination, the annular pancreas has been found to possess normal acinar and islet tissue1. Diagnosis is often made on X-ray which may show 2 gas shadows with air-fluid levels (double-bubble sign) or a dumb-bell shaped shadow2. In adults the diagnosis is often made by radiologic dcmonstration of a hugely dilated 1st part of duodenum in barium study (See [Figure - 1]).
Some patients with annular pancreas may live without symptoms and are diagnosed at autopsy. In others marked obstruction, occurring in adult life is usually due to inflammatory 5 changes with swelling and late fibrosis[5]. For these patients who have obstruction of the duodenum, the proper treatment is bypass of the area of obstruction by anastamosis of the proximal duodenum with the first part of the jejunum. The first successful reported case of duodeno-jejunostomy was by Gross and Chisolm[3]. Although bypass via gastrojejunostomy is also possible, occasional continuing abdominal pain due to undecompressed duodenum makes this procedure less desirable. Patient presenting with chronic pancreatitis have been successfully treated with pancreatico-duodenectomy4. Resection or division of annulus is inadvisable, since the risk of fistula formation and duodenal leakage increases when pancreatic tissue is dispersed throughout the duodenal wall[1],[5].
| 1. |
Boothroyd LSA. Annular pancreas. Ann Surg 1957; 146:139-144.  |
| 2. | Filly RA, Freimanis AK. Echographic diagnosis of pancreatic lesions: ultrasound scanning techniques and diagnostic findings. Radiology 1970; 96:575. |
| 3. | Gross RE, Chisholm TC. Annular pancreas producing duodenal obstruction. Report of a successfully treated case. Ann Surg 1944; 119:759-769. |
| 4. | Guillcmin G, Cuilleret J, Michel A, Berard P, Feroldi J. Chronic relapsing pancreatitis. Surgical management including sixty-three cases of pancreatico-duodenectomy. Amer J Surg 1971; 122:802-807. |
| 5. | Hays DM, Greenery EM Jr, Hill JT. Annular pancreas as a cause of acute neonatal duodenal obstruction. Ann Surg 1961; 153:103-112.
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