review of literature on clinical pancreatology - The Pancreapedia

the stomach and duodenum. Analysis <strong>of</strong> the CT findings included evaluation <strong>of</strong> the location,contour, growth pattern, border, enhancement pattern, and enhancement grade <strong>of</strong> the tumor,as well as the presence <strong>of</strong> surface dimpling, prominent enhancement <strong>of</strong> overlying mucosa,and low intralesional attenuation. The attenuation <strong>of</strong> each lesion, the long diameter (LD), theshort diameter (SD), and the LD/SD ratio were measured. The typical location (prepyloricantrum and duodenum), endoluminal growth pattern, ill-defined border, prominentenhancement <strong>of</strong> overlying mucosa, and an LD/SD ratio <strong>of</strong> greater than 1.4 were found to besignificant for differentiating ectopic pancreas from other tumors. When at least two <strong>of</strong> thesefive criteria were used in combination, the sensitivity and specificity for diagnosing ectopicpancreas were 100 percent (14 <strong>of</strong> 14) and 83 percent (33 <strong>of</strong> 40), respectively. When four <strong>of</strong>these criteria were used, a sensitivity <strong>of</strong> 43 percent and a specificity <strong>of</strong> 100 percent wereachieved [114].Ectopic pancreatic tissue within a duodenal diverticulum has not been previously describedin the English-language <strong>literature</strong>. It was reported a case <strong>of</strong> a 52-year-old woman whopresented with a perforated duodenal diverticulum after upper endoscopy. Operativeresection and repair <strong>of</strong> the perforated diverticulum was performed, and, on microscopicexamination, ectopic pancreatic tissue was found within the diverticulum [115].Circumportal annulareThere have been 6 cases <strong>of</strong> circumportal pancreas reported, and 2 <strong>of</strong> them had the mainpancreatic duct in a retroportal dorsal portion. This extremely uncommon anomaly isasymptomatic and therefore incidentally discovered. For the surgeon, it is important todiscover this during pancreatic resection so the pancreatic duct can be closed and fistula isavoided. It was now describe a third case where a circumportal pancreas had its mainpancreatic duct passing under the portal vein. The duct was identified and ligated. A fistuladid not occur [116].Pancreas annulareAnnular pancreas is a rare embryonal abnormality. Its manifestation in adulthood is <strong>of</strong>tenpinpointed with a substantial delay, which is most <strong>of</strong>ten attributed to pancreatitis, biliarypathology or dyspepsia. It was presented a case <strong>of</strong> a 28-year-old woman who hadexacerbating symptoms <strong>of</strong> high bowel obstruction from 20th week <strong>of</strong> pregnancy, progressingafter premature delivery. Diagnostic work-up revealed partial annular pancreas compressingthe duodenum. Despite attempts <strong>of</strong> conservative treatment, her state deteriorated to such anextent that surgery was indicated and gastrojejunal bypass created. Her postoperativerecovery was uneventful. In cases in which symptoms <strong>of</strong> high bowel obstruction in pregnancypersist and prostration occurs, we suggest close monitoring and a more thorough diagnosticapproach. The question remains whether annular pancreas presents a cause <strong>of</strong> pathologicfindings, a c<strong>of</strong>actor, or a mere accidental diagnosis in the development <strong>of</strong> superposedpathologies [117].The purpose <strong>of</strong> one study was to <strong>review</strong> the CT, MRI, and ERCP findings <strong>of</strong> annularpancreas in adults. A search <strong>of</strong> the radiology and ERCP databases at one institution forcases <strong>of</strong> annular pancreas in adults yielded the records <strong>of</strong> 42 patients who underwent 29ERCP, 22 CT, and 13 MRI examinations. Nine <strong>of</strong> 24 (38 %) cases <strong>of</strong> annular pancreasdetected with CT or MRI did not have a radiologically complete ring <strong>of</strong> pancreatic tissuesurrounding the second part <strong>of</strong> the duodenum. Three <strong>of</strong> the nine patients (33 %) withradiologically incomplete annular pancreas and six <strong>of</strong> the 15 patients (40 %) with completeannular pancreas had gastric outlet obstruction. The presence <strong>of</strong> pancreatic tissueposterolateral to the second part <strong>of</strong> the duodenum had a high sensitivity (92 %) andspecificity (100 %) for the presence <strong>of</strong> annular pancreas. The rates <strong>of</strong> pancreas divisum (37%) and chronic pancreatitis (48 %) were high in this cohort. It was concluded that annular