Annular pancreas is a congenital malformation but manifestations can appear in the adult life.
Annulus means a ring of pancreatic tissue around the duodenum. For annular pancreas to be diagnosed, this ring can be complete or incomplete.
Embryological basis
Normally the ventral buds of pancreas and dorsal bud fuses together. Non rotation and fusion of these two leads to the formation of annular pancreas. It envelops the 2nd part of duodenum.
Age of presentation
Incidence is equal in both adults and children
Presentation in children is congenital anomalies and duodenal obstruction
Presents in adults as pancreatitis usually in 3rd or 4th decade
Association with other pancreatic conditions
1. Pancreas divisum 35- 40%
2. Chronic pancreatitis 45- 50%
Other GI conditions
Annular pancreas is a possible etiology of congenital duodenal obstruction and is associated with other congenital anomalies such as Down syndrome, duodenal atresia, and imperforate anus.
Clinical Fetaures
Of those seen as adults, 75%were seen with pain
22% were diagnosed with pancreatitis
24%) had gastrointestinal (GI) symptoms that included vomiting,
11%had obstructive jaundice and/or abnormal liver function test results.
Treatment
It is duodenal bypass and not resection of duodenum as duodenum excision can lead to pancreatitis
in children its duodeno - duodenostomy
in adults duodenoduodenostomy which has now replaced duodenojejunostomy
Pancreas annulare in radiology refers to the imaging findings of a rare congenital anomaly where a ring of pancreatic tissue encircles the duodenum. On imaging, such as CT, MRI, or endoscopic ultrasound, it may present as a characteristic encircling or constricting mass around the duodenum, often associated with symptoms like duodenal obstruction.
The BISAP score (Bedside Index for Severity in Acute Pancreatitis) is used to predict the severity of acute pancreatitis. It includes 5 components, one point each:
Blood urea nitrogen (BUN) > 25 mg/dL
Impaired mental status (GCS < 15)
Systemic Inflammatory Response Syndrome (SIRS)
Age > 60 years
Pleural effusion on imaging
✅ WBC >16,000 is not directly part of the BISAP score, although it is a criterion within SIRS, which is part of BISAP.
In radiation proctitis, surgery is typically indicated for complications that are severe or unmanageable through conservative measures. The options can be considered as follows:
A) Pain Abdomen: While abdominal pain can be a symptom associated with radiation proctitis, it is not an indication for surgery on its own. Pain management and other conservative treatments can be employed first.
B) Rectal stricture: This can cause significant obstruction and may require surgical intervention to restore normal bowel function.
C) Haemorrhage: Severe bleeding due to radiation proctitis may necessitate surgical intervention if it is not controlled by endoscopic or conservative measures.
D) Vesical Fistula: The formation of a fistula between the bladder and rectum (vesical fistula) is a serious complication that often requires surgical repair.
Acute Radiation proctitis - Occurs within 6 mths of starting the treatment
Chronic - After 6 mths, Most patients develop symptoms at a median of 8 to 12 months after completion of radiotherapy
Modified Radiation Therapy Oncology Group rectal toxicity scale
Grade 1
Mild and self-limiting
Minimal, infrequent bleeding or clear mucus discharge, rectal discomfort not requiring analgesics, loose stools not requiring medications
Grade 2
Managed conservatively, lifestyle (performance status) not affected
Intermittent rectal bleeding not requiring regular use of pads, erythema of rectal lining on proctoscopy, diarrhea requiring medications
Grade 3
Severe, alters patient lifestyle
Rectal bleeding requiring regular use of pads and minor surgical intervention, rectal pain requiring narcotics, rectal ulceration
Use of newer conformal radiation therapy techniques.
Amifostine is a prodrug that is metabolized to a thiol metabolite that is thought to scavenge reactive oxygen species
Placebo-controlled phase III trials have detected no benefit from either topical or oral sucralfate.
Treatment of radiation proctitis
Medical
Butyrates
ASA
Sucralfate
Metronidazole
Short chain FA
Topical formalin
Hyperbaric o2
Endoscopic
dilatation
Heater and bipolar cautrey
ND YAG
APC
RFA
Surgery
Diverting ostomies for severe stricture - Better for incontinence, stricture and limited benefit for bleed
Reconstruction with Flaps - rectourethral or rectovaginal fistula with a pedunculated gracilis or a Martius flap to facilitate healing by introducing well-vascularized healthy tissue,
Proctectomy complicated fistulous disease, especially when accompanied by significant pain and incontinence, or in cases of severe and intractable bleeding
Q) Supraduodenal CBD is supplied by all except (AIIMS NOV 18) a Cystic art b RHA c LHA d Anterosuperior pancreaticoduodenal artery
Ans c
The blood supply to the right and left hepatic ducts and upper portion of the CHD is from the CA and the right and left hepatic arteries.
The supraduodenal bile duct is supplied by arterial branches from the right hepatic, cystic, posterior superior pancreaticoduodenal, and retroduodenal arteries.
arteries to the supraduodenal bile duct run parallel to the duct at the 3 and 9 o’clock positions.
Approximately 60% of the blood supply to the supraduodenal bile duct originates inferiorly from the pancreaticoduodenal and retroduodenal arteries
whereas 38% of the blood supply originates superiorly from the right hepatic artery and CD artery
Q. Least common complication of Meckel's diverticulum is
a) Bleeding
b) Obstruction
c) Neoplasm
d) Obstruction
While many individuals remain asymptomatic, complications of Meckel's diverticulum can lead to significant clinical issues requiring medical intervention.
Answer is free
Ans ) c Neoplasm
The most common clinical presentation of Meckel’s diverticulum is gastrointestinal bleeding, which occurs in 25% to 50% of patients who present with complications.
Bleeding is often due to ulceration of the diverticulum. This bleeding can manifest as painless rectal bleeding
Another potential complication is intestinal obstruction, which can occur if the diverticulum becomes incarcerated or twisted. This situation may lead to bowel ischemia and perforation if not managed quickly.
Intestinal obstruction occur as a result of a volvulus of the small bowel around a diverticulum associated with a fibrotic band attached to the abdominal wall, intussusception, or, rarely, incarceration of the diverticulum in an inguinal hernia (Littre hernia)
Diverticulitis accounts for 10% to 20% of symptomatic presentations.
Neoplasms can also occur in a Meckel’s diverticulum, with NET as the most common malignant neoplasm (77%). Other histologic types include adenocarcinoma (11%), which generally originates from the gastric mucosa, and GIST (10%) and lymphoma (1%).
Complications of Meckel's diverticulum can be recognised and managed early if there is high index of suspicion
Q) False regarding the management of Acute Diverticulitis, Sigmoid colon inflammation and Fat stranding in CT ?
a) Outpatient treatment in most cases
b) Do a colonoscopy after the resolution of acute symptoms
c) Elective Colectomy to be done
d) IV antibiotics to be started`
The pathogenesis of acute diverticulitis is often attributed to the obstruction of diverticula by fecaliths, leading to increased intraluminal pressure, bacterial overgrowth, and subsequent inflammation or perforation
Answer Free c
Sigmoid diverticulitis can be complicated and uncomplicated
Complicated means diverticulum associated with abscess, perforation, obstruction, fistula
This question is about an uncomplicated acute diverticulitis
It can be managed in outpatient setting
It requires IV antibiotics and diet modification
After resolution of symptoms, colonoscopy is to be done after 6 weeks to rule out the presence of other diverticula and neoplasm
Colectomy is not required in all cases. Current recommendations suggest that the decision for surgery should be individualized, taking into consideration the frequency and severity of recurrences. The patient’s overall medical condition and comorbidities should also be included in the analysis
Q) A 60 year old male is contemplating hyperbaric oxygen therapy for radiation proctitis. Which of the following is not true regarding this?
A. Indicated in acute radiation proctitis but not in subacute or chronic radiation proctitis B. Oxygen increases the growth of residual tumor and hence tumor should be completely resected C. Complications include Parkinsonism, barotrauma D. Usually 30-40 sessions are required for treatment
Ans a
This statement is not true because hyperbaric oxygen therapy (HBOT) is not only indicated in acute radiation proctitis but can also be beneficial in subacute and chronic radiation proctitis. Studies have shown that HBOT can promote healing in chronic radiation injuries as well.
Hyperbaric oxygen overcomes chronic tissue hypoxia in radiation damaged tissues and with repeated sessions induces growth of regenerative tissue, capillaries, and epithelium. Successful therapy may take multiple sessions. 18 to 60 treatments
HBO treatments for hypoxic wounds are usually delivered at 1.9 to 2.5 atm for sessions of 90 to 120 minutes each. Treatments are given once daily, five to six times per week and should be given as an adjunct to surgical or medical therapies. Clinical evidence of wound improvement should be noted after 15 to 20 treatments.
Complications of HBO therapy are caused by changes in atmospheric pressure and elevated PO2. Middle ear barotrauma, ranging from tympanic membrane hyperemia to eardrum perforation, is the most common complication.
Pneumothorax brain oxygen toxicity, manifested by convulsions resembling grand mal seizures; oxygen lung toxicity, resulting from damage from oxygen free radicals to lung parenchyma and airways and ranging from tracheobronchitis to full-blown respiratory distress syndrome; and transient myopia.
Absolute contraindications to HBO therapy are
(1) uncontrolled pneumothorax
(2) current or recent treatment with bleomycin or doxorubicin (potential aggravation of cardiac and pulmonary toxicity), and
(3) treatment with disulfiram (increases risk of developing oxygen toxicity).
Q) All are true about pancreatic protocol CT except (#AIIMS )
a) > 90% of un resect able lesions are picked up by CT
b) It is a dual phase CT with cuts taken at 40 secs and 70 secs
c) Liver metastasis are detected in early arterial phase
d) All are true
Ans c
Pancreatic protocol CT involves imaging at the pancreatic phase (i.e., approximately 45 seconds after contrast administration) and at the portal venous phase (i.e., approximately 70 seconds after contrast administration).
It is useful for detection of adenocarcinoma of pancreas.
Metastatic lesions are seen in the portal venous phase, because the lesions are not typically well vascularized.
Arterial phase images are principally used to distinguish metastatic disease from benign vascular lesions, such as hemangiomas, or to better define the arterial anatomy of the liver.
Non contrast phase used for
Evaluation of pancreatic calcifications and allows localization of the precise levels for imaging on the post contrast study.
Early arterial phase
Evaluation of pancreatic vasculature without interference from venous opacification.
Late Arterial Phase
Distinguish pancreatic neoplasms from adjacent normal pancreatic tissue It also is useful to evaluate hypervascular liver metastases as seen in patients with neuroendocrine tumors of the pancreas.
Portal Phase
Evaluate for hypovascular liver metastases
Ref Blumgart
The dedicated pancreas protocol uses 750 to 1000 mL of oral water as a negative contrast agent administered before the examination, to aid distinction of enhanced vessels from the
gastrointestinal tract
Q) 45 year old male is having recurrent UTI . Best specimen for culture in UTI A. Midstream urine at anytime B. Midstream urine at early morning C. First voided sample D. Any urine sample
