A 25–year–old lady presented with abdominal pain, bloating, nausea, vomiting and diarrhea since one year and 15 pound weight loss since two months. Patient had consulted several physicians before with no avail. Physical exam revealed epigastric tenderness. Labs showed normal hemogram, electrolytes, renal and liver function, amylase, lipase and gastrin levels. Anti endomysial antibodies and ANCA were negative. Stool studies for ova, parasites and clostridium difficile toxin were negative. Pregnancy test was negative and gynecologic etiologies were ruled out. Esophagogastroduodenoscopy showed dilated erythematous stomach with bile, deeply ulcerated pylorus with exuberant granulation tissue and a strictured eccentric lumen that precluded further scope advance. Antral biopsy showed chronic gastritis but no Helicobacter pylori. Upper GI series to delineate the anatomy demonstrated duodenal obstruction by annular pancreas (Image 1). Computed Tomography scan of abdomen confirmed the pancreatic anomaly and delayed gastric emptying (Image 2). During the hospital course, patient had difficulty tolerating oral intake and required total parentral nutrition. Surgical team was consulted for Loop Gastrojejunostomy leading to successful resolution of symptoms. Intraoperative findings revealed thickened pylorus and proximal duodenum and an annular pancreas around the second portion of duodenum.
In patients hospitalized for persistent symptoms of peptic ulcer disease in the absence of common causes like H. pylori, NSAID use etc, suspicion for unusual etiologies like gastrinoma, crohn’s disease, carcinoid or congenital malformations should be raised. Annular pancreas is one such unusual cause of peptic ulcer disease and duodenal obstruction. It is a rare embryologic anomaly characterized by pancreatic tissue completely or partially surrounding the second part of duodenum. Estimated prevalence is 5–15 cases per 100,000 adults on autopsy and 400 cases per 100,000 on ERCP. As in this case sometimes a complete pancreatic annulas is not appreciated radiologically, but the diagnosis is confirmed on GI series and surgery.
Annular pancreas a rare anomaly, can present as recurrent peptic ulcer disease and symptoms of duodenal obstruction.
Image 1Arrows pointing incomplete pancreatic annulas.
Image 2GI Series.