Ansa Pancreatica Research Articles

Endoscopic Ultrasound in Pancreatic Duct Anomalies.

Embryological development of the pancreas is a complex phenomenon and, therefore, it can have multiple developmental aberrations. Fortunately, the majority of these pancreatic ductal anomalies are asymptomatic with no clinical relevance and are incidentally detected during diagnostic cross-sectional imaging or endoscopic retrograde cholangiopancreatography (ERCP) or autopsy. Occasionally, pancreatic duct anomalies can result in symptoms like abdominal pain or recurrent pancreatitis. Also, an accurate pre-operative diagnosis of ductal anomalies can prevent inadvertent duct injury during surgery. Conventionally, ERCP had been used for an accurate diagnosis of pancreatic duct anomalies. However, because it is invasive and associated with a risk of pancreatitis, it has been replaced with magnetic resonance cholangiopancreatography (MRCP). MRCP has demonstrated high sensitivity and specificity for the diagnosis of ductal anomalies, which can be further improved with the use of secretin-enhanced MRCP. Endoscopic ultrasound (EUS) is a new diagnostic and interventional tool in the armamentarium of endoscopists and has demonstrated promising results in the detection of pancreatic duct variations and anomalies. Along with the visualization of the course and configuration of the pancreatic duct, EUS can also visualize changes in the pancreatic parenchyma, thereby helping with an early diagnosis of any co-existent pancreatic disease. Absence of the stack sign and crossed duct sign are important EUS features to diagnose pancreas divisum. EUS can also help with the diagnosis of other congenital ductal anomalies like annular pancreas, ansa pancreatica, and anomalous pancreaticobiliary union, although the published experience is limited.

S2233 Looped in Inflammation: The Link Between Ansa Pancreatica and Acute Pancreatitis

S2233 Looped in Inflammation: The Link Between Ansa Pancreatica and Acute Pancreatitis

S1946 ANSA Pancreatica and Recurrent Acute Interstitial Pancreatitis: An Emerging Anatomic Variant

S1946 ANSA Pancreatica and Recurrent Acute Interstitial Pancreatitis: An Emerging Anatomic Variant

Anatomical pancreatic variants in intraductal papillary mucinous neoplasm patients: a cross-sectional study

BackgroundNo previous studies have examined the possible relationship between intraductal papillary mucinous neoplasm (IPMN) and the developmental ductal variations of the pancreas, such as an ansa pancreatica and a meandering main pancreatic duct (MMPD).MethodsThis retrospective cross-sectional study enrolled 214 patients, 108 with IPMN disease and 106 subjects from a community at the tertiary care unit. The main pancreatic duct (MPD) was evaluated in the head of the pancreas by its course, which were non-MMPD: descending, vertical, and sigmoid, or MMPD including loop types, reverse-Z subtypes, and an N-shape, which was identified for the first time in this study. IPMN patients were also evaluated for worrisome features (WF) or high-risk stigmata (HRS), and the extent of IPMN cysts.ResultsAmong IPMN patients, 18.4% had MMPD, which we observed in only 3.0% of the control group (P < 0.001). Patients with MMPD were more likely to belong to the IPMN group compared with non-MMPD patients [odds ratio (OR) 6.4, 95% confidence interval (CI) 2.2–24.9]. Compared with a descending shape MPD, IPMN patients with an N-shaped MPD were more likely to have a cystic mural nodule (OR 5.9, 95% CI 1.02–36.0). The presence of ansa pancreatica associated with more extent IPMN disease (OR 12.8, 95% CI 2.6–127.7).ConclusionsIPMN patients exhibited an MMPD more often than control patients. Ansa pancreatica associated with multiple cysts. Furthermore, an N-shape in IPMN patients associated with cystic mural nodules, suggesting that this shape serves as a risk factor for more severe IPMN.

Recurrent pancreatitis in the setting of gallbladder agenesis, ansa pancreatica and santorinicoele

Recurrent pancreatitis in the setting of gallbladder agenesis, ansa pancreatica and santorinicoele

Intraoperative pancreatoscopy for surgical planning in a patient with ansa pancreatica and mixed-type intraductal pancreatic mucinous neoplasm

Intraoperative pancreatoscopy for surgical planning in a patient with ansa pancreatica and mixed-type intraductal pancreatic mucinous neoplasm

Anatomical Patterns of the Pancreatic Ductal System – A Cadaveric and Magnetic Resonance Cholangiopancreatography Study

Abstract Introduction Morphological variants of the pancreatobiliary system can predispose to chronic pancreatitis. The goal of the present study is to assess the prevalence of pancreatic duct patterns in the Indian population, both by cadaveric dissection and by magnetic resonance cholangiopancreatography (MRCP). Materials and Methods A total of 15 adult pancreas specimens of unknown age and gender, and 5 fetal pancreas specimens of different gestational ages with the intact second part of duodenum, were dissected by the piecemeal method. For clinical relevance, MRCP images of 103 clinically-diagnosed chronic pancreatitis patients irrespective of their etiology were obtained retrospectively from the existing database and studied. The anatomical patterns were classified as five different types based on the course of the main pancreatic duct and the accessory pancreatic duct and their openings into the duodenal wall, including variants like pancreas divisum and ansa pancreatica. Results In the cadaveric study, the main pancreatic duct was single with a straight course in 46.67% of the adult specimens, and in the MRCP study, the main pancreatic duct showed a descending course in 77.66% of the cases. The most common pattern was type III in both the cadaveric (80%) and radiological (55.33%) studies, and the accessory duct was absent on the MRCP in all type-III cases, while it ended blindly in the cadaveric specimens. Ansa pancreatica (type V) was observed in 1 adult specimen (6.7%), but not in the radiological study. Pancreas divisum (type IV) was observed in the 8 cases (7.76%) cases in the radiological study. Conclusion Knowledge of the anatomical variants of the pancreatic ductal system may be helpful for the radiologists during diagnostic and therapeutic interventional procedures.

2182 Endoscopic Challenges in a Patient With Ansa Pancreatica and Recurrent Pancreatitis

INTRODUCTION: Ansa pancreatica is a rare anatomical variation of the pancreatic duct where there is communication between the ventral pancreatic duct, which forms an ansa loop, and the accessory pancreatic duct. Its prevalence is estimated to be 1% in general population, and its presence can predispose to acute pancreatitis. We present an interesting and rare case of chronic pancreatitis with a pancreatic duct stricture in the setting of ansa pancreatica. CASE DESCRIPTION/METHODS: A 54-year-old female with a heterozygous CFTR mutation and a long-standing history of recurrent acute and now chronic pancreatitis. Two weeks after an episode of acute pancreatitis, a magnetic resonance cholangiopancreatography (MRCP) was performed showing a new stricture in the pancreatic duct near the genu, with pre-stenotic ductal dilation. Two prior endoscopic retrograde cholangiopancreatographies had been performed to attempt pancreatic duct endotherapy, but these were unsuccessful in achieving deep wire cannulation beyond the ansa loop. (image 1A-1B). The pancreatic duct in the genu of the pancreas was noted to have moderate stenosis on MRCP (image 1C). After a discussion with the patient, the decision was made to re-attempt endoscopic therapy. The ventral pancreatic duct was initially cannulated. The 0.025 inch angled guidewire was again unable to navigate the ansa loop and into the distal pancreas. Thereafter, we attempted dorsal pancreatic duct cannulation via the monir papilla. The guidewire was advanced successfully beyond the stricture and into the opacified body and tail (image 1D). The minor papilla and the stricture in the genu were dilated with a 7 Fr catheter dilator. After a minor papillotomy a 7 Fr by 8 cm plastic stent was placed into the dorsal pancreatic duct (image 1E, 2). The stent was removed 6 weeks later, and the duct remained patent. The patient has had no recurrence of acute pancreatitis to date. DISCUSSION: While the prevalence of ansa pancreatica is low, its presence can have great impact on the necessary approach for endoscopic therapy in chronic pancreatitis. In our case, the patient failed several ERCP attempts via ventral duct cannulation, and endoscopic therapy was successful only when cannulation of dorsal pancreatic duct was performed. In conclusion, in patients with chronic pancreatitis, recognition of ansa pancreatica, when present, is important to guide the endoscopic approach to treatment as minor papilla cannulation, a necessary skill for the interventional endoscopist, may be required.

Uncommon Anatomic Variation of the Pancreatic Duct: Ansa Pancreatica

Uncommon Anatomic Variation of the Pancreatic Duct: Ansa Pancreatica

Ansa pancreatica. Review of the literature

Ansa pancreatica is a reversed S-shaped pancreatic duct arising from the main pancreatic duct of Wirsung and ending at or near the minor duodenal papilla. Described for the first time in 1961, it is a rare anatomic variant of the pancreatic ducts system and is characterized by the absence of the accessory duct of Santorini. It probably serves as a counter measure after the accessory duct obliteration, in order to maintain sufficient pancreatic juice drainage. The literature concerning ansa pancreatica seems to be rather poor, compared to other anatomic variants and congenital anomalies of the pancreatic ducts. We tried to define the ansa pancreatica incidence among general population and highlight the possible differences between different populations, and to define its possible correlation with pancreatitis. The existing data correlate ansa pancreatica with recurrent acute pancreatitis and pancreatitis in alcoholics. Despite the lack of extended data, ansa pancreatica is a rare anatomic variant, proven to play an important role in certain clinical conditions.

Case report on Ansa Pancreatica: A rare cause of recurrent Pancreatitis in Children

Acute recurrent pancreatitis is a rare entity in children. It can be caused by a number of reasons, anatomical variations being one of them. Panctreatica divisum is the most common form of ductal anomaly while ansa pancreatica has been the least studied and explored. In recurrent pancreatitis, Ansa Pancreatica was recently found to be a key risk factor. It is usually found among adult alcoholics. We submit the report of a rare but important cause of acute recurrent pancreatitis; an 11-year-old child with 2 previous episodes of pancreatitis was diagnosed with ansa pancreati ca on magnetic resonance cholangiopancreatography (MRCP). He was advised to get stenting of Pancreatic duct. To the best of our belief, only another case has been reported in the paediatric population.

Endoscopic Management of Ansa Pancreatica in a Patient With Recurrent Pancreatitis

Ansa pancreatica is an uncommon variation of pancreatic duct (PD) anatomy. Most individuals have a main PD and an accessory duct. In a small fraction of the population, a sigmoid loop or “ansa” forms a connection between both ducts. This anomaly usually persists without consequence, though impaired pancreatic fluid drainage could result in recurrent bouts of abdominal pain and pancreatitis at any time during life. More cases are now being uncovered as previously classified idiopathic pancreatitis and to date, there is limited evidence for the role of therapeutic intervention in ansa pancreatica. A 63-year-old man presented for evaluation after his third episode of pancreatitis in four years. Prior investigation into the etiology of pancreatitis was remarkable for endoscopic ultrasound (EUS) showing PD dilation and a two centimeter cyst concerning for papillary mucinous neoplasm. Fine needle aspiration of the lesion did not reveal any malignant cells and tumor markers were negative. Yet, pancreaticoduodenectomy was offered to prevent further episodes of pancreatitis. Not entirely settled on undergoing major surgery, the patient sought a second opinion. During our encounter, repeat EUS identified a single branch coming off the PD with ventral duct dilation and bulging of the minor duodenal papilla, all findings consistent with ansa pancreatica. Endoscopic retrograde cholangiopancreatography with spyglass examination of the PD was performed. A stent was placed in the ventral PD and ventral sphincterotomy performed. Several months later, the patient remains without pain while living an active life. Pancreatic duct abnormalities are potential risk factors for pancreatitis. The most common anomaly is divisum, which occurs in approximately ten percent of individuals. Ansa pancreatica is less known and likely underdiagnosed. Incorporating this differential diagnosis into a meticulously evaluated patient can help guide superior visualization techniques for anatomical clarity. In this case, we believe that the sigmoid loop created an anechoic signal that was misdiagnosed as a cyst on initial EUS. This error was confirmed by computed tomography of the abdomen that excluded any pancreatic cyst. We chose ductal stenting with sphincterotomy to relieve any associated obstruction; however, continued surveillance is necessary to assess the sustained efficacy of this measure.

The anatomical variations of pancreatic duct in the patients with pancreatic diseases

There are many anatomic variations of pancreatic duct and congenital anomalies of pancreas, which have been described in the literature. Most of them has no clinical significance and is used to be incidentally discovered in radiological examinations. We have demonstrated in our paper that the most frequent anatomical variations of pancreatic duct in the patients with pancreatic diseases are pancreas divisum as well as ansa pancreatica.

Groove Pancreatitis: Endoscopic Treatment via the Minor Papilla and Duct of Santorini Morphology.

Background/AimsGroove pancreatitis (GP) is an uncommon disease involving the pancreaticoduodenal area. Possible pathogenesis includes obstructive pancreatitis in the duct of Santorini and impaired communication with the duct of Wirsung, minor papilla stenosis, and leakage causing inflammation. Limited data regarding endoscopic treatment have been published.MethodsSeven patients with GP receiving endoscopic treatment were reviewed. The morphology of the pancreatic duct was evaluated by a pancreatogram. Endoscopic dilation of the minor papilla and drainage of the duct of Santorini were performed.ResultsThere were two pancreatic divisum cases, one ansa pancreatica case and four impaired connections between the duct of Santorini and the main pancreatic duct. Three to 31 sessions of endoscopy, with 2 to 24 sessions of transpapillary stenting and dilation, were performed. Interventions through the minor papilla were successfully performed in six of seven cases. The pancreatic stenting duration ranged from 2 to 87 months. Five patients with evidence of chronic pancreatitis (CP) tended to receive more endoscopic interventions than did the two patients without CP (2–24 vs 2, respectively) for GP and other complications associated with CP.ConclusionsDisconnection or impairment of communication between the ducts of Santorini and Wirsung was observed in all cases of GP. No surgery was required, and endoscopic minor papilla dilation and drainage of the duct of Santorini were feasible for the treatment of GP.

Transduodenal drainage of symptomatic walled-off pancreatic necrosis in a patient with ansa pancreatica anatomic variation.

Endoscopic transmural drainage is an effective treatment for patients with walled-off pancreatic necrosis (WOPN) [1]. Transmural endoscopic drainage of WOPN is based on total removal of the necrotic content through a stoma formed between the lumen of the gastrointestinal tract (stomach or duodenum) and the cavity of the necrotic collection [2].

Anatomic variations of the pancreatic duct and their relevance with the Cambridge classification system: MRCP findings of 1158 consecutive patients.

BackgroundThe study was conducted to evaluate the frequencies of the anatomic variations and the gender distributions of these variations of the pancreatic duct and their relevance with the Cambridge classification system as morphological sign of chronic pancreatitis using magnetic resonance cholangiopancreatography (MRCP).Patients and methodsWe retrospectively reviewed 1312 consecutive patients who referred to our department for MRCP between January 2013 and August 2015. We excluded 154 patients from the study because of less than optimal results due to imaging limitations or a history of surgery on pancreas. Finally a total of 1158 patients were included in the study.ResultsAmong the 1158 patients included in the study, 54 (4.6%) patients showed pancreas divisum, 13 patients (1.2%) were defined as ansa pancreatica. When we evaluated the course of the pancreatic duct, we found the prevalence 62.5% for descending, 30% for sigmoid, 5.5% for vertical and 2% for loop. The most commonly observed pancreatic duct configuration was Type 3 in 528 patients (45.6%) where 521 patients (45%) had Type 1 configuration.ConclusionsVertical course (p = 0.004) and Type 2 (p = 0.03) configuration of pancreatic duct were more frequent in females than males. There were no statistically significant differences between the gender for the other pancreatic duct variations such as pancreas divisium, ansa pancreatica and course types other than vertical course (p > 0.05 for all). Variants of pancreas divisum and normal pancreatic duct variants were not associated with morphologic findings of chronic pancreatitis by using the Cambridge classification system. The ansa pancreatica is a rare type of anatomical variation of the pancreatic duct, which might be considered as a predisposing factor to the onset of idiopathic pancreatitis.

Ansa pancreatica as a predisposing factor for recurrent acute pancreatitis.

AIMTo determine the non-biased prevalence and clinical significance of ansa pancreatica in patients with acute pancreatitis using magnetic resonance imaging (MRI).METHODSOur institutional review board approved this cross-sectional study, which consisted of a community-based cohort of 587 consecutive participants in a whole-body health-check program, and 73 subjects with episode of acute pancreatitis (55 patients with a single episode of acute pancreatitis, and 18 patients with recurrent acute pancreatitis). All of the subjects underwent abdominal MRI including magnetic resonance cholangiopancreatography, medical examinations, and blood tests. Two board-certified, diagnostic, abdominal radiologists evaluated the images, and ansa pancreatica was diagnosed based on its characteristic anatomy on MRI.RESULTSCompared with the community group [5/587 (0.85%)], patients with recurrent acute pancreatitis had a significantly higher frequency of ansa pancreatica [2/18 (11.1%)] (P = 0.016; OR = 14.3; 95%CI: 1.27-96.1), but not compared with patients with single-episode acute pancreatitis [1/55 (1.8%)] (P = 0.42; OR = 2.1; 95%CI: 0.44-19.7). Multiple logistic regression analysis using age, alcohol intake, presence of ansa pancreatica, and presence of autoimmune disease as independent covariates, revealed a significant relationship between the presence of ansa pancreatica and recurrent acute pancreatitis. The presence of autoimmune disease was also significantly associated with the onset of recurrent acute pancreatitis. On the other hand, neither age nor alcohol intake were significantly related to the onset of recurrent acute pancreatitis.CONCLUSIONThe present study is the first to provide robust evidence that the presence of ansa pancreatica is significantly associated with recurrent acute pancreatitis.

Accessory pancreatic duct patterns and their clinical implications.

Accessory pancreatic duct (APD) designed to reduce the pressure of major pancreatic duct by forming a secondary drainage channel. Few studies have mentioned the variant types of accessory ducts and their mode of formation, some of these have a clear clinical significance. Present study is aimed to evaluate the possible variations in the APD and its terminations. Forty formalin fixed adult human pancreas with duodenum in situ specimens were studied by injecting 1% aqueous eosin, followed by piece meal dissection of the head of the pancreas from posterior surface. Formation, tributaries, relations, and the termination of the accessory pancreatic duct were noted and photographed. Accessory ducts revealed 50% belonged to long type, 22.5% were of short and ansa pancreatica type each, and embryonic type of duct pattern was seen in 5% specimens. 75% of long type ducts showed positive patency with eosin dye, followed by ansa type (44.4%), and least patency was found in short type (22.2%). With regard to the patency of the accessory pancreatic ducts towards their termination, we found 52.5% of the accessory ducts and 5% of the embryonic type pancreatic ducts were patent and in 42.5% of the specimen the ducts were obliterated. In 85% of specimens the minor duodenal papillae was anterosuperior to the major papilla and superior to the major papillae in 10% of the cases, and in 5% minor papillae was absent. The average distance between the two papillae was 2.35 cm. The knowledge of the complex anatomical relations of the gland with its duct, duodenum and bile ducts are essential for the surgeons and sinologists to plan and perform both the diagnostic as well as therapeutic procedures effectively.

Complete Pancreas Divisum with an Ansa Pancreatica

Pancreas divisum is the most common congenital pancreatic anomality and is seen in more than 5% of the general population. In many cases, this variant is a coincidental finding at endoscopy or imaging studies, but it is also implicated as a cause of acute recurrent pancreatitis in some patients. Here the author shows an endoscopic retrograde cholangiopancreatography of a patient with complete pancreas divisum with an ansa pancreatica, and demonstrate the typical findings and techniques for cannulation of the ventral and dorsal pancreatic ducts. Moreover, several variants of pancreas divisum are illustrated. This article is part of an expert video encyclopedia.

Ansa pancreatica: an anatomic variation and a rare cause of acute pancreatitis

The ansa pancreatica is a rare anatomic variation of the pancreatic ducts. It is a communication between the main pancreatic duct (Wirsung) and the accessory pancreatic duct (Santorini). Recently, the ansa pancreatica has been considered as a predisposing factor in patients with idiopathic acute pancreatitis. \We report a case of non-alcoholic and non-biliary acute pancreatitis, in a 53-year-old patient. An ansa pancreatica was discovered in a post-operative cholangiography. A pancreatic duct variation, as the ansa pancreatica, can be diagnosed during a severe acute pancreatitis. It is still not clear whether the presence of these two pathologies is a coincidence or if the ansa pancreatica is the cause of the acute pancreatitis. New studies are necessary to clarify these points.