Diagnosis of agenesis of the dorsal pancreas with MR pancreatography

Agenesis of the Dorsal Pancreas: A Rare Cause of Diabetes and Recurrent Upper Abdominal Pain

Agenesis of the dorsal pancreas is a rare congenital disorder with only a handful of cases described in the literature. It presents a diagnostic dilemma. Cross-sectional imaging is the cornerstone for diagnosis. It could have a syndromic association with polysplenia and cardiac anomalies. Pancreas divisum and chronic pancreatitis may present with similar symptoms and must be ruled out. We present a case of a 55-year-old male with recurrent non-specific abdominal pain and diabetes mellitus. He was managed with insulin and painkillers for symptomatic relief. We also reviewed approximately 68 cases described in the literature to date.

Failure to Thrive in a Middle-Aged Female: A Case of Congenital Incomplete Pancreas From a Rare Genetic Defect

Hepatocyte nuclear factor-1 beta (HNF1B) gene is predominantly expressed in the liver, kidney, lung, genitourinary tract, and pancreas. It is an important transcription factor that regulates pancreas development. Mutation or absence of this gene is rare and can cause incomplete pancreatic development known as the agenesis of the dorsal pancreas. This rare genetic abnormality is associated with other disorders like maturity-onset diabetes of the young, abnormal liver function tests, genitourinary tract malformation, pancreatitis, and renal cysts. Diagnosing this genetic abnormality is difficult, especially in patients presenting with symptoms specific to only one system. Management is based on disease manifestation and involves a multidisciplinary approach. Our case describes a 51-year-old female with poorly controlled diabetes mellitus and Mullerian duct anomalies who presented with abdominal pain, fatigue, dizziness, and electrolyte derangement. Contrast-enhanced computed tomography (CECT) of the abdomen showed a multicystic kidney and a pancreatic head with a missing body and tail. Further workup revealed an HNF1B mutation.

Agenesis of the dorsal pancreas with chronic suppurative pancreatitis: Case report and literature review

RATIONALE

Agenesis of the dorsal pancreas (ADP) is a rare congenital anomaly of the pancreas. ADP is associated with some other medical problems such as diabetes mellitus, abdominal pain/bloating, pancreatitis, pancreatic neuroendocrine tumor and so on. In this study, we present a case of ADP with chronic suppurative pancreatitis, summarize the clinical characteristics of the reported cases in China and review the correlative literature.

PATIENT CONCERNS

A 51-year-old Chinese man, with a history of impaired fasting glucose, presented with jaundice, pruritus and dark urine. Laboratory analysis showed abnormal liver function and elevated carbohydrate antigen 19-9.

DIAGNOSES

Contrast-enhanced computed tomography demonstrated a mass located at the head of pancreas and complete absence of the body and tail of pancreas. Endoscopic retrograde cholangiopancreatography demonstrated an eccentric malignant stricture about 1.6cm of distal common bile duct.

INTERVENTIONS

The patient underwent pancreaticoduodenectomy because of the suspicion of pancreatic tumor. The postoperative pathological result was chronic suppurative pancreatitis, with moderate hyperplasia in focal ductal epithelium.

OUTCOMES

A long-term follow-up shows that the patient is asymptomatic with well-controlled diabetes mellitus and pancreatic exocrine insufficiency.

LESSONS

ADP is a quite rare congenital malformation of the pancreas with poorly-understood pathogenesis. The diagnosis of ADP depends on the imaging examination. The therapeutic strategy varies from person to person due to the different accompanying conditions.

A Rare Case of Dorsal Agenesis of Pancreas, Choledochal Cyst, and Hirschsprung Disease in a Young Patient

Dorsal pancreatic agenesis is a rare congenital pancreatic malformation. There is just 1 reported case associating it with choledochal cyst. However, no cases have reported yet with both coexisting with Hirschsprung disease. We report a case of a 23-year-old man, presenting with on and off epigastric pain, sometimes radiating to the back. His medical records showed he had Hirschsprung disease as a neonate, for which he underwent Duhamel procedure. Ultrasound imaging revealed a choledochal cyst and a nonvisualized distal portion of the pancreas. Further cross-sectional imaging confirmed the findings—a type 1 choledochal cyst and a dorsal agenesis of the pancreas in a patient with Hirschsprung disease.

Complete agenesis of dorsal pancreas with pancreatic cyst: A case report

Agenesis of the dorsal pancreas (ADP) is extremely rare disease with no specific symptoms and there is no clear pathogenesis. Approximately half of the affected individuals develop diabetes resulting from reduced islet cell mass secondary to lack of endocrine structures. In this case, we aimed to present a 17-year-old female patient with ADP accompanied by a pancreatic cyst.

Two cases of agenesis of the dorsal pancreas and a review of the literature

Background

Agenesis of the dorsal pancreas (ADP) is a very rare disease with no specific symptoms, and the pathogenesis is not clear. Some patients will be accompanied by other diseases, such as pancreatic tumor or pancreatitis. But most cases are very atypical and difficult to distinguish. Some syndromes of pancreatic exocrine insufficiency are common in patients with ADP. Here, we report two cases of ADP and summarize the clinical features, diagnosis, and treatment of ADP.

Case presentation

Case A is a 65-year-old Chinese woman who presented with abdominal pain accompanied by nausea, bloating and acid reflux. The enhanced abdominal CT scan found nothing meaningful except the absence of the body and tail of the pancreas. The diagnosis was considered as gastrointestinal dysfunction cause by exocrine pancreatic insufficiency and recovered after symptomatic treatment. Case B is a 61-year-old Chinese woman who presented with abdominal pain accompanied by fever, vomiting and bloating. The abdominal CT showed multiple stones in the gallbladder, and the body and tail of the patient’s pancreas were absent. She was diagnosed with cholelithiasis and recovered after laparoscopic cholecystectomy.

Conclusion

Agenesis of the dorsal pancreas (ADP) is a rare congenital disease with an unclear pathogenesis that presents multiple symptoms. It should be considered when the patients have non-specific, persistent and unexplained symptoms such as bloating or uncontrolled blood sugar. Imaging examination is helpful for diagnosis. And it does not require surgical intervention unless it accompanies other diseases, EPI need to be considered when the non-specific gastrointestinal symptoms appear.

Three cases of pancreatic pseudocysts associated with dorsal pancreatic agenesis

Agenesis of the dorsal pancreas (ADP) is an extremely rare congenital anomaly. Human pancreas is formed by ventral and dorsal endodermal buds of the foregut endoderm. The dorsal bud forms the upper part of the head, neck, body, and tail of the pancreas and the ventral bud generates most of the head and uncinate process. ADP is derived from the embryologic failure of the dorsal pancreatic bud to form the pancreatic body and tail. ADP can be related to some diseases and conditions such as pancreatitis, hypoglycemia, and rarely pancreatic tumors. The association between cystic lesions with ADP has previously been reported. Three cases of cystic lesions of the pancreas with ADP were diagnosed clinically based on the imaging features and without any past history of pancreatitis. However, the pathologic diagnosis of resected lesions confirmed pseudocysts without pathologic evidence of tumor. We report 3 cases of pancreatic pseudocysts associated with ADP

Agenesis of the dorsal pancreas associated with mucinous adenocarcinoma and cystic teratoma: a case report and literature review

Dorsal agenesis of the pancreas is a rare congenital anomaly. Fifty‐eight cases were reported from 1913 till 2015, nine of which were associated with tumors. We present the 10th case, the first to be associated with pancreatic mucinous adenocarcinoma and cystic teratoma, successfully managed by Whipple procedure and total pancreatectomy.

Complete agenesis of the dorsal pancreas: A rare clinical entity

Complete agenesis of the dorsal pancreas (ADP) is an exceedingly rare congenital anomaly, compatible with life. The first case was reported in 1911 and so far around 100 cases have been reported in the world literature. Majority of the patients with this anomaly are asymptomatic or associated with abdominal pain, hyperglycemia, diabetes mellitus, and acute or chronic pancreatitis. We present a case report of a 34-year-old male with ADP, diagnosed incidentally during radiological evaluation for abdominal pain. Magnetic resonance cholangiopancreatography confirmed the absence of neck, body, and tail of the pancreas along with duct of Santorini and the minor duodenal papilla. Because of its rarity of occurrence, clinical awareness of the ADP can expand the differential diagnosis and improve patient management in pertinent light of the world literature.

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.

Congenital pancreatic anomalies, variants, and conditions

Understanding pancreatic development and the congenital anomalies and variants that result from alterations in normal development allows for better recognition of these anomalies at diagnostic imaging. This article reviews normal pancreatic embryology and anatomy, and the appearance of the more common developmental anomalies and ductal variants, with emphasis on computed tomography and magnetic resonance imaging. Common mimics of masses are also covered.

Dorsal agenesis of the pancreas - a rare cause of abdominal pain and insulin-dependent diabetes

Dorsal agenesis of the pancreas is a rare congenital disorder. We report a case of a 65-year-old man with mild abdominal pain and insulin-dependent diabetes mellitus. Computed tomography (CT) of the abdomen showed a short pancreas with no pancreatic tissue ventral to the splenic vein. Magnetic resonance cholangiopancreatography (MRCP) visualized the absence of a dorsal duct system and confirmed the suspicion of complete agenesis of the dorsal pancreas. Endoscopic ultrasound (EUS) was also performed to rule out pancreatic malignancy.

Does pancreatic ductal anatomy play a role in determining outcomes of pancreatic anastomoses?

Pancreatoduodenectomy (PD) is the surgical procedure performed for cancers of the head of the pancreas. Despite a substantial reduction in mortality rates following PD, morbidity remains high secondary to major post-operative complications. Post-operative pancreatic fistula (POPF), the commonest major complication following PD, results from the failure of the pancreato-enteric anastomosis. There appears to be a correlation between intrinsic pancreatic features like the texture of the gland and duct size and the outcome of the pancreatic anastomosis. Based on current clinical research data, we propose a new hypothesis called the "pancreatic ductal anatomy" concept. We hypothesize that morphological variations, anomalies or aberrations of the main pancreatic duct play a role in the outcome of the pancreatic anastomosis, irrespective of its type. The consequence of aberrant ductal anatomy is that certain areas of the remnant pancreas remain either undrained or partially drained, or have blocked ductules/ducts. This results in localized obstructive pancreatitis causing an inflammatory reaction which jeopardizes the anastomosis. We also propose two maneuvers which could possibly play a role in predicting potential problems and also planning the surgical resection and reconstruction in order to reduce the incidence of POPF. The first modality is the use of pre-operative magnetic resonance imaging (MRI) of the pancreatic duct, and the second maneuver is the gentle cannulation test of the pancreatic duct with a soft, narrow tube following transection of the pancreatic neck. These factors would alert the surgeon about potential ductal variations and could facilitate the surgical approach.

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.

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.

Agenesis of the dorsal pancreas: a case report and review of the literature

Partial or complete agenesis of the dorsal pancreas is a rare congenital anomaly that results from the embryological failure of the dorsal pancreatic bud to form the body and tail of the pancreas. To date, four cases have been reported in Korea. We report an additional case; a 25-year-old woman presented with diabetes mellitus and abdominal pain. Abdominal computed tomography (CT) revealed a normal-appearing pancreatic head, but the body and tail were not visualized. Endoscopic cholangiopancreatogram (ERCP) revealed a short pancreatic duct in the uncinate process and the head and the duct of Santorini draining into the minor papilla. Abdominal magnetic resonance imaging (MRI) findings were similar to the CT and ERCP results. The patient was diagnosed with partial agenesis of the dorsal pancreas by CT, ERCP and MRI.

CT differentiation of distal pancreas fat replacement and distal pancreas agenesis

We aimed to describe CT signs useful for differentiation of distal agenesis from distal or dorsal pancreas lipomatosis. Multidetector CT (MDCT) studies of five patients with distal pancreas agenesis (n = 2), distal lipomatosis (n = 1), distal short pancreas (n = 1), and distal pancreatectomy (n = 1) were retrospectively reviewed. Agenesis of dorsal pancreas can be diagnosed by the absence of body and tail of pancreas. In the absence of distal pancreas, distal pancreatic bed can be filled by stomach or intestine (dependent stomach or dependent intestine signs), which abut splenic vein. Same findings can be seen in patients with distal pancreatectomy, however, splenic vein is absent in these patients. In case of distal lipomatosis abundant fat tissue is observed anterior to splenic vein. Dependent stomach and/or dependent intestine signs on MDCT imaging can allow differentiation of distal pancreas agenesis from distal lipomatosis obviating further diagnostic studies.

Case report: solid-pseudopapillary tumour of the pancreas associated with dorsal agenesis

Solid-pseudopapillary tumour of the pancreas is a rare benign or low-grade malignant epithelial tumour; its association with pancreatic dorsal agenesis has been reported only once before. We present the radiological and histological findings of a case of pancreatic solid-pseudopapillary tumour associated with total pancreatic dorsal agenesis. A 49-year-old woman presented with abdominal pain radiating to the back for several months. Radiological findings showed absence of the dorsal pancreas and an 8 cm x 6 cm diameter tumour arising from the head of the pancreas. She underwent successful complete resection of the tumour. Histopathology revealed a diagnosis of solid-pseudopapillary tumour.

Comparison between magnetic resonance cholangiopancreatography and ERCP for evaluation of the pancreatic duct

OBJECTIVE

To date, ERCP has been the reference technique in the diagnosis of pancreatic duct pathology. The aim of the present study was to evaluate the accuracy of magnetic resonance cholangiopancreatography (MRCP), a relatively new, noninvasive diagnostic method, in studying the pancreatic duct.

METHODS

A prospective 15-month study was done of 78 patients with suspected biliopancreatic pathology and indications for ERCP. In all cases, MRCP was performed <72 h before ERCP. Both techniques were used to assess the size of the pancreatic tract (normal or dilated), the presence or absence of obstruction, the level of obstruction where present, and its etiology.

RESULTS

Both techniques found the pancreatic tract to be normal and nondilated in 60 patients. The specificity and sensitivity of MRCP in evaluating the normal pancreatic duct were 98% and 94%, respectively. In nine cases, a stenotic duct of Wirsung was detected (seven at the head of the pancreas and two in the body), with the same correlation being shown by ERCP (sensitivity 100%). The sensitivity and specificity of MRCP relating to diffuse irregular and dilated morphologies of the entire pancreatic duct was 86% and 100%, respectively. Nine patients were diagnosed with pancreatic neoplasms by both techniques, with an accuracy of 100%. Four patients presented chronic pancreatitis, which was correctly diagnosed by MRCP in each case.

CONCLUSIONS

MRCP is an effective technique for evaluating both the normal and diseased duct of Wirsung, and for establishing the underlying pathology.