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    Annular Pancreas (Anular Pancreas)

    An annular pancreas is a congenital anomaly in which the pancreas either partially or completely encircles the duodenum, resulting in the obstruction of the gastrointestinal tract or the biliary tree. Epigastric discomfort, and nausea, followed by relief after vomiting are the main symptoms. The diagnosis is made through the use of imaging studies and invasive upper gastrointestinal endoscopy.

    Annular Pancreas is related to the following process: congenital.

    Presentation

    Annular pancreas, defined as encircling of the duodenum by the pancreas due to improper embryonal development, was initially considered to be a rare finding in clinical practice, with an incidence rate of approximately 1 in 20,000 newborn babies [1] [2]. However, it is recognized as the second most common congenital anomaly of the pancreas (after pancreas divisum), and studies show that up to 1 in 250 individuals have this congenital abnormality, but not all patients develop symptoms [3]. It is diagnosed in two patient populations - in newborns and adults [2] [4] [5]. In newborns, severe obstruction of the duodenum with vomiting is the main presenting symptom [2] [6]. Down syndrome (trisomy 21) has been strongly associated with annular pancreas [3]. On the other hand, the condition may be asymptomatic until adulthood, and patients between 20-60 years of age (more specifically within the 30-50 year range period) can develop a sudden onset of epigastric pain, nausea, relief after vomiting and post-prandial fullness, while hematemesis is seen in about 10% of cases [1] [5]. In addition, an increased incidence of peptic ulcer disease (PUD), acute pancreatitis, biliary obstruction, and jaundice, as well as pancreatic carcinoma is noted in this patient population [1] [6]. It is not uncommon for annular pancreas to be detected incidentally [1] [5].

    Entire body system
    Down Syndrome
    Falling
    • Cases usually fall in two age groups - infantile (from birth to 4 years) and adults (from 17 onwards).[jpgmonline.com]
    Inflammation
    • Exams and Tests A health care provider will suspect Q fever if you have history of exposure to the Coxiella burnetii bacteria and develop: Inflammation of the inside lining of the heart and heart valves Flu-like symptoms Inflammation of the liver Pneumonia[aspirus.org]
    • Blockage of the duodenum develops if inflammation (pancreatitis) develops in the annular pancreas.[en.wikipedia.org]
    • Disease Peritonitis Peritonitis is an inflammation (irritation) of the peritoneum.[scripps.org]
    • : inflammation of the tissue that lines the inner wall of the abdomen In addition, adults who have annular pancreas have a higher risk for developing certain types of cancer, including biliary tract and pancreatic cancer.[healthline.com]
    • - there is more inflammation that requires hospitalization, careful replacement of body fluid that may be lost and there is usually no permanent damage Severe - the inflammation progresses to tissue death, shock, infection, failure of many organs and[yoursurgery.com]
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  • gastrointestinal
    Abdominal Bloating
    • Side effects of pancreatic enzymes are rare but can include abdominal bloating, gas, hyperglycemia (14), and fibrosing colonopathy, which was primarily seen in children with cystic fibrosis receiving high dose pancreatic enzymes (4).[pancreapedia.org]
    Bilious Vomiting
    • […] not through vomiting tho coz both will have bilious vomiting![forums.studentdoctor.net]
    • The usual presentation is with bilious vomiting and intolerance to feed, however, the patient may have associated prolonged jaundice.[jpss.eu]
    • […] from the annular portion may drain into the main pancreatic duct or directly into the duodenum * Clinical Findings Frequently asymptomatic May present either in infancy or, more commonly, 4 th -5 th decade of life In newborn, duodenal obstruction with bilious[learningradiology.com]
    • The main form of presentation is vomiting, which in 90% of cases is the vomiting of food, and not bilious vomiting, because the most frequent location is preampullary. 2 Other types of presentations are pancreatitis, peptic ulcer and obstructive jaundice[elsevier.es]
    Chronic Abdominal Pain
    • As explained above, acute recurrent pancreatitis had a higher response rate than chronic pancreatitis or chronic abdominal pain associated with pancreas divisum.[emedicine.medscape.com]
    • In older children and adults, it can cause similar symptoms and chronic abdominal pain.[saintlukeshealthsystem.org]
    Vomiting
    • […] not through vomiting tho coz both will have bilious vomiting![forums.studentdoctor.net]
    • The main form of presentation is vomiting, which in 90% of cases is the vomiting of food, and not bilious vomiting, because the most frequent location is preampullary. 2 Other types of presentations are pancreatitis, peptic ulcer and obstructive jaundice[elsevier.es]
    • […] annular portion may drain into the main pancreatic duct or directly into the duodenum * Clinical Findings Frequently asymptomatic May present either in infancy or, more commonly, 4 th -5 th decade of life In newborn, duodenal obstruction with bilious vomiting[learningradiology.com]
    • Clinical features: • Abdominal pain and swelling, nausea or vomiting. • Note: symptoms absent without pancreatitis Exams and Tests: • Abdominal ultrasound • Abdominal CT scan • Amylase and lipase blood test Treatment: • Surgery.[slideshare.net]
    • Nausea and vomiting are the usual symptoms and reflect the intestinal obstruction.[medicinenet.com]
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  • Workup

    Because certain reports have identified its surprisingly common occurrence, annular pancreas must be included in the differential diagnosis of unexplained gastrointestinal complaints. In neonates and in adults, the role of a detailed patient history revealing the course and progression of symptoms is of pivotal importance, whereas a carefully obtained physical examination is equally important in the assessment of such complaints. Once valid clinical suspicion is raised about a gastrointestinal pathology, imaging studies should be employed. Plain radiography, although being of little benefit in the evaluation of the GI tract, can detect air in the dilated stomach and the duodenal bulb (known as the double-bubble sign) [1] [2]. Abdominal ultrasonography is of limited use in evaluating hollow organs, and so radiological techniques like computed tomography (CT) and magnetic resonance imaging (MRI) are favored [1] [7]. The presence of pancreatic tissue completely or partially surrounding the duodenum is a cardinal feature of annular pancreas [7]. The anomaly may not be large enough to be confirmed through non-invasive imaging studies, however, which is why more direct methods are often necessary to determine the cause of GI symptoms. Magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP), and endoscopic ultrasonography (EUS) are recommended procedures definitive diagnosis [1] [2] [3] [6] [7].

    Test Results

    Amniocentesis
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  • Laboratory

    Serum
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  • Imaging

    X-ray
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  • CT
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  • Ultrasound
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  • Treatment

    Prognosis

    Complications

    Annular Pancreas
    Congenital Abnormality
    • INTRODUCTION Annular pancreas is a rare congenital abnormality characterized by a ring of pancreatic tissue surrounding the descending portion of the duodenum.[uptodate.com]
    • It has a prevalence of one in 2,000 persons and occurs either as an isolated finding or with other congenital abnormalities.[manju-imagingxpert.blogspot.com]
    • Clinical Annular pancreas is a rare congenital abnormality in which a ring of pancreatic tissue encircles the duodenum at or above the major papilla.[med-ed.virginia.edu]
    • Typically, in such cases, other congenital abnormalities are present in the infant, together with Annular Pancreas, thus increasing its mortality If the symptoms occur during adulthood, then with prompt and appropriate treatment, the prognosis is usually[dovemed.com]
    • Both the rarity of this congenital abnormality and its successful correction by surgical means have prompted us to make this presentation. 5.[dx.doi.org]
    Duodenal Atresia
    • But I look at it like this, Duodenal atresia will most likely be complete blockage while annular pancreas will be partial blockage - so in real life, Duodenal atresia will most likely show up on the 1st day of life, while annular pancreas may not show[forums.studentdoctor.net]
    • As in other forms of duodenal atresia, malformations of the cranial intestine are also frequently present in patients with annular pancreas.[orpha.net]
    • Google Scholar Shih HS, Ko SF, Chaung JH: Is there an association between duodenal atresia and choledochal cyst?.[bmcgastroenterol.biomedcentral.com]
    • Duodenal atresia and stenosis.[jpss.eu]
    • Since duodenal atresia or duodenal stenosis occurs in all cases of annular pancreas, the anomalous pancreas should be considered a secondary change rather than a primary cause of duodenal obstruction. so probably in the question they should not offer[usmleforum.com]
    Duodenal Obstruction
    • Jaundice neonatorum is usually prolonged in case of any congenital duodenal obstruction.[jpss.eu]
    • The main goal of treatment is the relief of the duodenal obstruction.[joplink.net]
    • If the encirclement is complete, it may be associated with complete or incomplete duodenal obstruction.[usmleforum.com]
    • Annular pancreas is one such unusual cause of peptic ulcer disease and duodenal obstruction.[shmabstracts.com]
    • However, it can cause duodenal obstruction in adults.[radiopaedia.org]
    Dystocia
    • The baby was born to a 20-year old primigravida, in that hospital, through a Caesarian section due to cervical dystocia.[jpss.eu]
    Intestinal Obstruction
    • Nausea and vomiting are the usual symptoms and reflect the intestinal obstruction.[medicinenet.com]
    • ., Chebbi, F. and Sassi, S.A. (2011) A rare cause of proximal intestinal obstruction in adults—Annular pancreas: A case report.[scirp.org]
    • Chebbi A rare cause of proximal intestinal obstruction in adults: annular pancreas: a case report Pan Afr Med J, 10 (2011), pp. 56 2 J.[elsevier.es]
    • The most frequently found symptoms are: abdominal pain (70%), vomiting and nausea (47%), and they are generally reflecting a proximal intestinal obstruction [8].[dx.doi.org]
    • Symptoms: • Usually non-specific • Abnominal pain & dyspepsia Diagnosis: • GI endoscopy Complication: • Intestinal obstruction • Carcinoma of the ectopic pancreatic tissue Treatment: • Surgery if symptomatic 20. • Results from anomalous development of[slideshare.net]
    Pancreatitis
    • It can result from growth of a bifid ventral pancreatic bud around the duodenum, where the parts of the bifid ventral bud fuse with the dorsal bud, forming a pancreatic ring.[en.wikipedia.org]
    • Pancreatitis and the risk of pancreatic cancer.[pancreapedia.org]
    • RVP, right ventral pancreatic anlage; LVP, left ventral pancreatic anlage; DP, dorsal pancreatic anlage.[hindawi.com]
    • Annular pancreas associated with diffuse chronic pancreatitis.[joplink.net]
    Polyhydramnios
    • Early signs of abnormality include polyhydramnios (an excess of amniotic fluid), low birth weight, and feeding intolerance immediately after birth.[en.wikipedia.org]
    • Early signs of abnormality include polyhydramnios, low birth weight and feeding intolerance immediately after birth.[imedpub.com]
    • Annular pancreas has been associated with maternal polyhydramnios and congenital abnormalities such as Down syndrome, esophageal and duodenal atresia, imperforate anus, and Meckel's diverticulum [ 4-6 ].[uptodate.com]
    • Conditions that may be associated with annular pancreas include: Down syndrome Excess amniotic fluid during pregnancy (polyhydramnios) Other congenital gastrointestinal problems Pancreatitis Newborns may not feed well.[nlm.nih.gov]
    Small Bowel Obstruction
    • Radiology Plain films may demonstrate proximal small bowel obstruction.[med-ed.virginia.edu]
    • Evidence Based Medicine Research for Annular pancreas Medical research articles related to Annular pancreas include: Duodenal Atresia Tracheoesophageal Fistula (Overview) Small-Bowel Obstruction (Diagnosis) Pancreatitis, Chronic (Overview) Duodenal Atresia[rightdiagnosis.com]
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  • Etiology

    Epidemiology

    Sex distribution
    Age distribution

    Pathophysiology

    Prevention

    Summary

    Patient Information

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    References

    1. Rondelli F, Bugiantella W, Stella P, et al. Symptomatic annular pancreas in adult: Report of two different presentations and treatments and review of the literature. Int J Surg Case Rep. 2016;20(Suppl):21-24.
    2. 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.
    3. Mittal S, Jindal G, Mittal A, Singal R, Singal S. Partial annular pancreas. Proc (Bayl Univ Med Cent). 2016;29(4):402-403.
    4. Patra DP, Basu A, Chanduka A, Roy A. Annular Pancreas: A Rare Cause of Duodenal Obstruction in Adults. Indian J Surg. 2011;73(2):163-165.
    5. Kasper DL, Fauci AS, Hauser SL, Longo DL, Jameson J, Loscalzo J. eds. Harrison's Principles of Internal Medicine, 19e. New York, NY: McGraw-Hill; 2016.
    6. Sandrasegaran K, Patel A, Fogel EL, Zyromski NJ, Pitt HA. Annular pancreas in adults. AJR Am J Roentgenol. 2009 Aug;193(2):455-60.
    7. Alahmadi R, Almuhammadi S. Annular Pancreas: A Cause of Gastric Outlet Obstruction in a 20-Year-Old Patient. Am J Case Rep. 2014;15:437-440.

    • Annular pancreas - MM Ravitch, AC Woods Jr - Annals of Surgery, 1950 - ncbi.nlm.nih.gov
    • Alveolar capillary dysplasia: a cause of persistent pulmonary hypertension of the newborn - J Alameh, A Bachiri, L Devisme, P Truffert - European journal of , 2002 - Springer
    • Annular pancreas divisum—a report of two cases and review of the literature - RE England, MK Newcomer, JWC Leung - British journal of , 1995 - Br Inst Radiology
    • Annular pancreas causing localized recurrent pancreatitis in a child: report of a case - Y Ohno, T Kanematsu - Surgery today, 2008 - Springer


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