Pancreas

Annular pancreas

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Management of annular pancreas

Q) All are true about annular pancreas except ( AIIMS GI Surgery Question bank)

a) They are mostly asymptomatic

b) It has equal incidence in children and adults

c) Treatment of choice is duodenojejunostomy

d) Associated with Down's syndrome

Answer c

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

Sabiston

Questions on Pancreas 

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.

BISAP Score In Pancreatitis

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Q) All are components in BISAP score except?

a) Age more than 60 years

b) WBC more than 16000

c) GCS <15

d) BUN > 25 mg/dl

Ans )b

Correct Answer: b) WBC more than 16000

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:

  1. Blood urea nitrogen (BUN) > 25 mg/dL

  2. Impaired mental status (GCS < 15)

  3. Systemic Inflammatory Response Syndrome (SIRS)

  4. Age > 60 years

  5. 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.

Pancreatic protocol CT

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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

Blumgart page 345

Free Answer

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Severe Acute Pancreatitis

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Q)  Ideal time for CECT in severe acute pancreatitis is
A. After 72 hours
B. After 48 hours
C. 24 hours
D. At admission

Answer for premium members

Mild acute pancreatitis 

  1. enlargement of the pancreas with loss of definition of the borders of the pancreas. 
  2.  Thickening of the right or left anterior pararenal fascia 

Severe Acute pancreatitis 

 Main determinant of clinical outcome is the degree of systemic organ disturbance, particularly during the early hours and days after admission to hospital

More than half of all deaths in AP occur within the first 2 weeks of illness  and are usually a consequence
of multiple organ failure

The revised Atlanta Classification 
3  grades of severity of pancreatitis:

Mild AP—characterized by the absence of organ failure or local
complications

Moderately severe AP—defined by...................read on 

 

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