Chronic pancreatitis sparing the annular pancreas

Abstract

Figure Legend: This magnetic resonance cholangiopancreatogram (MRCP) belongs to a 55-year old woman who presented with recurrent episodes of epigastric pain radiating to the back. She had a previous history of cholecystectomy. On the MRCP, an annular pancreas was identified. The pancreatic parenchyma in the body and tail was atrophic. There was dilatation of the main pancreatic duct and the side branches giving it a ‘chain of lakes’ appearance (arrowheads) in the body. The pancreatic duct in the region of the tail showed irregular dilatation. Multiple calculi were seen in the duct. The duct and parenchyma at the annulus (arrow), however, appeared unaffected by the disease process, which was confirmed by inspection and palpation at the time of surgery. A lateral pancreaticojejunostomy was performed, following which the patient has been asymptomatic for one year. Histopathological examination of themultiple biopsies taken from the diseased pancreatic duct showed features of chronic pancreatitis. Although annular pancreas generally presents in childhood with duodenal obstruction, it may manifest later in life with abdominal pain, vomiting, obstructive jaundice and pancreatitis (acute or chronic). Chronic pancreatitis in a patient with annular pancreas affects the annulus and spares the body and tail of the pancreas. This is usually attributed to an obstruction to flow in the annular duct. In this case, however, the annulus was entirely free of any disease. Despite a thorough literature search for a similar pattern of chronic pancreatitis in an adult with annular pancreas, no published report could be found.