An adult sympomatic case of annular pancreas preoperatively diagnosed by an endoscopic pancreatography

Abstract

This report is concerned with an adult symptomatic case of annular pancreas which was diagnosed by an endoscopic retrograde pancreatography. Review of English and Japanese literatures on the subject was also attempted. Our patient is a male of fifty three year of age with chief comhlaints of a longstanding postprandial abdominal fullness Believed by vomiting and recurrent episores of recent onset of fever, jaundice, and upper abdominal pain. Upper gastrointedtinal roentogen examination revealed a ssymmetric dilatation of the duodenal bulb and eccentric smooth annular defect of the outer margin at the junction of the first and second portion of the duodenum. These findings were noted constantly on repeated examinatiosn and were accentuated in the right anterior oblique position. Duodenofiberscopy revealed a major papilla just below the stenotic portion at the medial aspect of the second portion of the duodenum. Swelling of the longitudinal fold of the major papilla was noted. An endoscopic retrograde pancreatography showed a peculiar abnormality of the pancreatic duct system: Not only the 'duct of the annular portion but also the main pancreatic duct which passed through the tail and body of the pancreas in a usual way run to the right across the anterior surface of the duodenum, around the right side and again to the left across the posterior surface finally to open into the major papilla. Our preoperative diagnosis was as follows.(1) Annular pancreas with a peculiar pancreatic duct system as revealed by an endoscopic pan- creatography.(2) Recurrent episodes of cholangitis either due to choledochal stenosis induced by inflammation of the annular portion of the pancreas or due to formation fo stones in the biliary tract. Cholecystectomy, duodenojejunostomy, and choledo-chojejunostomy were performed. The gall bladder contained five stones and the choledochus a large stone of 12mm in diameter.Postoperative diagnosis are as follows.(1) A complete annular pancreas.(2) Duodenal stenosis.(3) Choledocholithiasis and cholelithiasis. Biopsy specimens taken from the annular portion and the body of the pancreas showed normal histology.