Annular Pancreas and Agenesis of the Dorsal Pancreas in a Patient with Polysplenia Syndrome

Polysplenia syndrome with situs ambiguous, common mesentery, and IVC interruption discovered incidentally in an adult

Polysplenia syndrome associates multiple spleens to other malformations, most frequently cardiac, vascular, visceral, and biliary malformations. Polysplenia has been described mainly in childhood owing to critical anatomic malformations related to cardiac defects or biliary atresia. We present a case of polysplenia syndrome found in a 58-year-old man. Only those with mild anatomical abnormalities reach adulthood without a diagnosis. Radiological examinations are helpful to the diagnosis by ascertaining the location and number of spleens, location of other organs in the chest and abdomen, and identification of other associated anomalies.

Left Upper-Quadrant Appendicitis in a Patient with Congenital Intestinal Malrotation and Polysplenia

Patient: Female, 13

Final Diagnosis: Left upper quadrant appendicitis

Symptoms: Left upper quadrant abdominal pain

Medication: —

Clinical Procedure: Laparoscopic ladd’s procedure

Specialty: Surgery

Polysplenia syndrome with duodenal and pancreatic dysplasia in a Holstein calf: a case report

Background

Laterality disorders of the abdominal organs include situs inversus totalis that mirrors the arrangements of all internal organs and heterotaxy syndrome (situs ambiguus) in which the thoracic or abdominal organs are abnormally arranged. Heterotaxy is often accompanied by multiple congenital malformations, and it generally comprises asplenia and polysplenia syndromes. To our knowledge, polysplenia syndrome has been reported in only three cattle, and computerized tomographic (CT) images of these animals were not obtained.

Case presentation

A six-month-old Holstein heifer had ruminal tympani and right abdominal distension. CT imaging showed that the rumen occupied the right side of the abdominal cavity, the omasum and abomasum occupied the left ventral side and the liver was positioned on the left. The colon and cecum were located at the left dorsum of the cavity, and the left kidney was located more cranially than the right. Postmortem findings revealed two spleens attached to the rumen. Significantly, the duodenum was too short to be divided into segments, except the cranial and descending parts, or flexures, except the cranial flexure, and the pancreas, which lacked a left lobe, was covered with mesojejunum. The liver comprised a relatively large right lobe and a small left lobe without quadrate and caudate lobes. The caudal vena cava that connected to the left azygous vein passed irregularly through the aortic hiatus of the diaphragm, and the common hepatic vein without the caudal vena cava passed through the caval foramen. Although the lungs and heart were morphologically normal, the right atrium received three major systemic veins. Polysplenia syndrome was diagnosed based on the CT and postmortem findings.

Conclusion

We defined the positions of the abdominal organs and morphological abnormalities in various organs of a calf with polysplenia syndrome based on CT and postmortem findings. These findings will improve understanding of the malpositioning and malformations that can occur in the organs of cattle with polysplenia syndrome.

Electronic supplementary material

The online version of this article (10.1186/s12917-017-1213-2) contains supplementary material, which is available to authorized users.

Coincidence of Polysplenia, Kartagener Syndrome, Dorsal Pancreas Agenesis, and Polycystic Kidney Disease in an Adult

Here we present the case of an adult male patient with the anomalies of polysplenia, Kartagener syndrome, dorsal pancreas agenesis, and adult polycystic kidney disease. Familiarity with this extremely rare coincidence may improve diagnostic accuracy and patient management.

Heterotaxy Polysplenia Syndrome In An Adult With Unique Vascular Anomalies: Case Report With Review Of Literature

The pattern of anatomical organization of the thoraco-abdominal visceral and vascular structures which is not the expected normal arrangement, is called as situs ambiguous or heterotaxy syndrome. Patients with heterotaxy syndrome exhibit a wide spectrum of anatomical variations involving thoraco-abdominal structures. We present here an incidental finding of heterotaxy syndrome associated with unique vascular anomalies in a 35 year old male patient evaluated initially for nephrolithiasis by ultrasonography, and intravenous pyelography. Further evaluation by multidetector row computed tomography showed bilateral bilobed lungs with hyparterial bronchi, cardiac apex to the left, five branches from left-sided aortic arch with retroesophageal right subclavian artery, interrupted inferior vena cava with azygos continuation, left renal vein continuing as hemiazygos vein and replaced common hepatic artery arising from the superior mesenteric artery. Other vascular anomalies include right internal iliac vein joining the left common iliac vein and precaval course of the single main right renal artery. Anomalies involving abdominal organs include right-sided stomach, midline liver, multiple splenules (polysplenia) in right upper quadrant of abdomen, short truncated pancreas, intestinal malrotation, inversion of superior mesenteric vessels and a preduodenal portal vein. To the best of our knowledge this is the first report of association of left renal vein continuing as hemiazygos vein, precaval right renal artery and anomalous branching pattern of aortic arch with heterotaxy syndrome.

"Ductal adenocarcinoma in anular pancreas"

INTRODUCTION

The annular pancreas is a congenital anomaly in which pancreatic tissue partially or completely surrounds the second portion of the duodenum. Its often located above of papilla of Vater (85%), rarely below (15%). This pancreatic tissue is often easily dissociable to the duodenum but there is same cases where it the tissue is into the muscolaris wall of the duodenum.

MATERIAL AND METHODS

We describe three case of annular pancreas hospitalized in our facility between January 2004 and January 2009. There were 2 male 65 and 69 years old respectively and 1 female of 60 years old, presented complaining of repeated episodes of mild epigastric pain. Laboratory tests (including tumor markers), a direct abdomen X-ray with enema, EGDS and total body CT scan were performed to study to better define the diagnosis. EUS showed the presence of tissue infiltrating the muscle layer all around the first part of duodenum. Biopsies performed found the presence of pancreatic tissue with focal areas of adenocarcinoma. Subtotal gastrectomy with Roux was performed. The histological examinations shows an annular pancreas of D1 with multiple focal area of adenocarcinoma. (T1aN0M0).

RESULTS

We performed a follow up at 5 years. One patients died after 36 months for cardiovascular hit. Two patients, one male and one female, was 5-years disease-free.

DISCUSSION

Annular pancreas is an uncommon congenital anomaly which usually presents itself in infants and newborn. Rarely it can present in late adult life with wide range of clinical severities thereby making its diagnosis difficult. Pre-operative diagnosis is often difficult. CT scan can illustrate the pancreatic tissue encircling the duodenum. ERCP and MRCP are useful in outlining the annular pancreatic duct. Surgery still remains necessary to confirm diagnosis and bypassing the obstructed segment.

Polysplenia syndrome detected after chest symptoms in two adult patients: case report and review of literature

Background

Polisplenia syndrome (PSS) is a rare subtype of heterotaxy syndrome and means ambiguous location of the major thoracic and abdominal organs with vascular anomalies and multiple spleens. We reported on the findings of computed tomography (CT) of PSS in adults, detected incidentally.

Case Report

Two woman underwent a CT examination of the thorax for different thoracic pathologies. There were common abnormalities such as hyparterial bronchi and absence of middle lobe fissure on CTscans suggesting heterotaxy syndrome. Therefore, the abdominal CTs were performed to detect the accompanying abdominal anomalies. Our two cases defined as PSS were diagnosed with multiple spleens in the normal location in the abdomen. The left-dominant liver and short pancreas with agenesis of the pancreatic tail and lateral part of the body were detected on CT scan. In the first case, the vascular abnormalities were as follows: variant entrance of the main portal vein into the liver and atypically located superior mesenteric vein (SMV) joining with the splenic vein to form the portal vein. In the second case, the preduodenal portal vein and hemiazygos continuation with interruption of the hepatic segment of the inferior vena cava (IVC) were the vascular anomalies. The bowels were malrotated in the second case.

Conclusions

Although such cases are usually admitted as abdominal emergency, our two cases were detected during examinations for thoracic and cardiac pathologies. The knowledge and awareness of PSS can be helpful to diagnose pathology and plan surgical procedures.

MR cholangiopancreatography of the pancreas and biliary system: a review of the current applications

MR cholangiopancreatography (MRCP) is still a rapidly evolving technique, but it has been already accepted as clinically useful and is widely used to evaluate biliary or pancreatic diseases. The advantages of this technique are that it does not use contrast media or ionizing radiation, it is noninvasive and complication free, and the examination is relatively short. MRCP has high sensitivity and specificity for diagnosing biliary dilatation and for determining the site and cause of stenosis. With further improvements of hardware and technique, MRCP is expected to replace diagnostic endoscopic retrograde cholangiopancreatography to examine the biliary and pancreatic ducts in the near future. The other applications include evaluation of primary sclerosing cholangitis, stenosis after liver transplantation, and bilioenteric anastomoses. This article reviews the current applications of MRCP in the evaluation of the pancreas and the biliary system.

Heterotaxy syndrome: a case report

Heterotaxy syndrome is defined as an abnormal arrangement of some organs and vessels in association with dysmorphism. The authors describe the case of a patient with heterotaxy syndrome with poliesplenia incidentally diagnosed during imaging evaluation (computed tomography and small bowel barium study) of unrelated pathological condition.

Sonographic features of agenesis of dorsal pancreas

Agenesis of dorsal pancreas is an extremely rare congenital anomaly that occurs due to failure of the dorsal pancreatic bud to form the body and tail of the pancreas. We report the sonographic appearance of this condition in six cases.

Polysplenia syndrome: a review of the relationship with viscero-atrial situs and the spectrum of extra-cardiac anomalies

Polysplenia syndrome is classified as one of the situs ambiguous or heterotaxy syndromes and is classically termed left isomerism or bilateral left-sidedness. However, polysplenia is a controversial and complex entity with no fixed pathognomonic features but rather a broad spectrum of abnormalities. In many published case series, polysplenia was neither associated with viscero-atrial heterotaxy nor with duplication of left-sided structures. The relationship between polysplenia and viscero-atrial situs is not clear. Several recent case reports describe the association of polysplenia with situs inversus totalis or with pancreatic; venous and other anomalies or with several types of malignancy. This article provides the reader with a review of the literature as well as our own experience aiming at better understanding of the polysplenia syndrome, its relationship with viscero-atrial situs and the spectrum of associated extra-cardiac anomalies.

Polysplenia syndrome with congenital agenesis of dorsal pancreas presenting as acute pancreatitis and the role of endoscopic ultrasonography in its diagnosis

A 49-year-old female was admitted to our hospital for acute pancreatitis. The abdomen CT scan incidentally showed midline liver with hepatomegaly, centrally located gallbladder, pancreas truncation, right sided small bowel, left sided large bowel, interruption of the inferior vena cava with azygos continuation, preduodenal portal vein, and multiple spleens in the left upper quadrant. In MRCP, the head of pancreas was enlarged and short main pancreatic duct without accessory duct was showed. EUS revealed enlarged ventral pancreas with a main pancreatic duct of normal caliber, absence of the accessory pancreatic duct and the dorsal pancreas. She was diagnosed as polysplenia syndrome with agenesis of dorsal pancreas. It is a rare congenital anomaly frequently associated with various visceral anomalies including multiple spleens, impaired visceral lateralization, congenital heart diseases, gastrointestinal abnormalities and azygos continuation of the inferior vena cava. We report a case of polysplenia syndrome with agenesis of dorsal pancreas presenting acute pancreatitis.

Polysplenia syndrome with agenesis of the dorsal pancreas and preduodenal portal vein presenting with obstructive jaundice--a case report and literature review

Polysplenia, as part of the heterotaxy syndrome, is a rare embryological disorder which results from failure of development of the usual left-right asymmetry of organs. It is often associated with cardiac and biliary abnormalities, which are the usual causes of death in early neonatal life. A congenitally short pancreas and abnormalities with portal vein formation, gut malrotations and inferior vena cava anomalies are known to be associated with this rare syndrome. We report a case of polysplenia in an adult female presenting with obstructive jaundice owing to choledocholithiasis, possibly formed by biliary stasis as a result of compression of the common bile duct by the preduodenal portal vein, and review the literature. The patient was also found to have complete agenesis of the dorsal pancreas on CT and endoscopic retrograde cholangiopancreatography.

Polysplenia syndrome accompanied with situs inversus totalis and annular pancreas in an elderly patient

Polysplenia syndrome (PS) is rarely encountered in elderly. It is characterized by multiple spleens associated with various cardiac and gastrointestinal abnormalities including partial or complete agenesis of dorsal pancreas. Situs inversus totalis (SIT) is a rare congenital anomaly with mirror image of viscera combined with dextrocardia. Occurrence of SIT and PS in the same patient is exceedingly rare. We present the first case of adult PS with SIT accompanied with annular pancreas.

Complications of congenital and developmental abnormalities of the gastrointestinal tract in adolescents and adults: evaluation with multimodality imaging

There is a wide variety of congenital anomalies that may affect the gastrointestinal tract. Most symptomatic congenital anomalies are found in newborns and infants. Such anomalies are relatively rare in adolescents and adults, and they may be difficult to identify because clinical symptoms often are nonspecific and insidious, causing them to be mistaken for other common abdominal conditions. Multimodality imaging is useful in evaluating congenital anomalies of the gastrointestinal tract in adults. The imaging features at radiography, fluoroscopy, ultrasonography, computed tomography, and magnetic resonance imaging may help identify congenital gastrointestinal anomalies such as congenital esophageal stenosis, gastric volvulus, duodenal web, annular pancreas, heterotopic pancreas, cecal volvulus, anomalies of the omphalomesenteric duct, Hirschsprung disease, and gastrointestinal duplication cyst. Familiarity with the imaging features of the various congenital anomalies of the gastrointestinal tract and their complications is important to establish the correct diagnosis and determine appropriate treatment, which is critical to avoid life-threatening complications.

Agenesis of the dorsal pancreas and its association with pancreatic tumors

Morphogenesis of the pancreas is a complex process; nevertheless, congenital anomalies are rare. At embryogenesis, the pancreas develops from the endoderm-lined dorsal and ventral buds of the duodenum. The ventral bud gives rise to the lower head and uncinate process of the pancreas; whereas, the dorsal bud gives rise to the upper head, isthmus, body, and tail of the pancreas. Rarely, developmental failure of the dorsal pancreatic bud at embryogenesis results in the agenesis of the dorsal pancreas--neck, body, and tail. Even rarer is the association of pancreatic tumors with agenesis of the dorsal pancreas. In addition to citing our case, we provide a comprehensive review on agenesis of the dorsal pancreas and its association with pancreatic tumors.

Agenesis of the dorsal pancreas and associated diseases

BACKGROUND

Agenesis of the dorsal pancreas is a very rare congenital pancreatic malformation and is associated with some other diseases.

METHODS

A PubMed search revealed 53 cases of agenesis of the dorsal pancreas.

RESULTS

In 28 patients with this congenital malformation hyperglycemia was demonstrated, 27 had abdominal pain, 16 had pancreatitis, 14 had an enlarged or prominent pancreatic head visible on computed tomography, and in a few cases, polysplenia, which may occur with various congenital anomalies of visceral organs, was described.

CONCLUSIONS

Difficulties involved in obtaining a firm diagnosis have led to a variety of terms being used to describe this congenital disease. Diagnosis of agenesis of the dorsal pancreas is inconclusive without demonstration of the absence of the dorsal pancreatic duct. Here we describe the embryological development of the pancreas, the so-far known cases of agenesis of the dorsal pancreas with associated medical problems, and the diagnostic measures to find the right conclusions.

Prenatal diagnosis of annular pancreas: reliability of the double bubble sign with periduodenal hyperechogenic band

OBJECTIVE

To evaluate the power of prenatal 2-D ultrasound examination in the 2nd trimester as a method of choice for accurate diagnosis of annular pancreas.

METHODS

Co-incidence of the double bubble sign (often accompanying gastroduodenal dilatation) together with a hyperechogenic band around the duodenum (corresponding with the tissue of annular pancreas) was used as a diagnostic criterion. Findings from postnatal surgery served for verification.

RESULTS

From 7,897 screened pregnancies, annular pancreas was proven in the cases where both signs were present, but never without the hyperechogenic band (N(1) = 3, N(2) = 3, p < or = 0.05). Sensitivity and specificity were 100%.

CONCLUSIONS

More multicentric studies are required to test this approach. The following diagnostic strategy is reasonable at the present time: when the double bubble sign is discovered, always suspect annular pancreas and look for the second sign: hyperechogenic bands around the duodenum. Also look for known associated anomalies, and vice versa, if any of associated anomalies are noted, also search specifically for the signs of annular pancreas.

Rare coincidence of congenital short and annular pancreas with gallbladder agenesis and splenic malrotation

We present an adult patient with anomalies of congenital short and annular pancreas, gallbladder agenesis and splenic malrotation. The patient presented with symptoms typical of the two pancreatic malformations and is the only reported case with these malformations reported in the English imaging literature.