Clinical implications of accessory pancreatic duct

Bile duct penetrating duodenal wall sign: a novel computed tomography finding of common bile duct stone impaction into duodenal major papilla

PURPOSE

Impacted common bile duct stones cause severe acute cholangitis. However, the early and accurate diagnosis, especially iso-attenuating stone impaction, is still challenging. Therefore, we proposed and validated the bile duct penetrating duodenal wall sign (BPDS), which shows the common bile duct penetrating the duodenal wall on coronal reformatted computed tomography (CT), as a novel sign of stone impaction.

METHODS

Patients who underwent urgent endoscopic retrograde cholangiopancreatography (ERCP) for acute cholangitis due to common bile duct stones were retrospectively enrolled. Stone impaction was defined by endoscopic findings as a reference standard. Two abdominal radiologists blinded to clinical information interpreted CT images to record the presence of the BPDS. The diagnostic accuracy of the BPDS to diagnose stone impaction was analyzed. Clinical data related to the severity of acute cholangitis were compared between patients with and without the BPDS.

RESULTS

A total of 40 patients (mean age 70.6 years; 18 female) were enrolled. The BPDS was observed in 15 patients. Stone impaction occurred in 13/40 (32.5%) cases. Overall accuracy, sensitivity, and specificity were 34/40 (85.0%), 11/13 (84.6%), and 23/27 (85.2%), respectively; 14/16 (87.5%), 5/6 (83.3%), and 9/10 (90.0%) for iso-attenuating stones; and 20/24 (83.3%), 6/7 (85.7%), and 14/17 (82.4%) for high-attenuating stones. Interobserver agreement of the BPDS was substantial (κ = 0.68). In addition, the BPDS was significantly correlated with the number of factors in the systemic inflammatory response syndrome (P = 0.03) and total bilirubin (P = 0.04).

CONCLUSION

The BPDS was a unique CT imaging finding to identify common bile duct stone impaction regardless of stone attenuation with high accuracy.

Frequency of Obliteration of the Dorsal and Ventral Ducts of the Pancreas in Islet Transplantation

BACKGROUND

Islet isolation is an essential process in every human islet transplantation protocol. Intraductal enzyme delivery followed by adequate distention of the pancreas is the most critical step in islet isolation. Anomalies of the pancreatic duct system can significantly affect this process. Thus, identification and characterization of ductal patency is of paramount importance to achieve optimal islet isolation.

AIMS

To investigate the frequency of duct obliteration in the human pancreas and explore donor/patient characteristics associated with specific ductal variations.

METHODS

We examined ductal patency of pancreata allocated for islet allotransplantation (n = 597) and autotransplantation (n = 21) after removal of the duodenum during islet isolation procedure. Donor/patient factors were reviewed from the batch files.

RESULTS

Among 559 deceased donor pancreata without pancreas divisum (n = 38, 6.4%), both ducts were patent in 50.1%, only ventral duct was patent in 46.7%, and only dorsal duct was patent in 3.2%. Donor age was not associated with the frequency of obliterated dorsal duct. Black race tended to have the higher frequency of patent dorsal duct. As expected, pancreas divisum was more frequent in chronic pancreatitis cases (n = 6, 28.6%). Within 7 cases of chronic pancreatitis with unknown etiology, we encountered one case of ventral duct obliteration.

CONCLUSIONS

The minor duodenal papilla and aging do not likely play an important role in the occurrence of dorsal duct obliteration. Although frequency of obliterated ventral duct was low in our population, physicians, including gastroenterologists and endoscopists, as well as islet transplantation researchers should be aware of this possibility.

Clinical importance of main pancreatic duct variants and possible correlation with pancreatic diseases

Background: Except for pancreas divisum (PD), the prevalence of anatomic variants of the main pancreatic duct (MPD) seems to be insufficiently investigated. To date, their role in the occurrence of pancreatic exocrine insufficiency (PEI) and morphological changes suggestive of chronic pancreatitis (CP) has remained unclear.Methods: A systematic review was performed, searching MEDLINE and Web of Science, limited to articles published between 1960 and 1 June 2019.Results: Our review included a total number of 3234 subjects. The most common variant of MPD was type 3, followed by type 1, indicating MPD drainage pattern into major papilla (MP) as the most frequent. A sub-variant of type 3, known as 'reverse pancreas divisum' had a prevalence of 2.2%. Type 4 variant- PD, was found in 6.4% of all cases. The most common sub-variant of PD was complete PD, followed by incomplete PD and variant with MPD as only pancreatic duct. Type 5 variant (including ansa pancreatica) was present in 2.9% of subjects. Apart from one study with a significantly higher frequency of morphological changes suggestive of CP in patients with ansa pancreatica, the studies stated no significant association between pancreatic disease and MPD variants. Furthermore, only one study examined the influence of MPD variants on exocrine pancreatic function. Although equivocal, this association is most likely found to be insignificant.Conclusion: To elucidate linkage between MPD variants and the occurrence of chronic pancreatitis and impairment of pancreatic exocrine function, further clinical investigations are warranted.

Abdominal Pain After Subtotal Gastrectomy: A First Report of Accessory Pancreatic Fistula

Background

The accessory pancreatic duct (APD) is the main drainage duct of the dorsal pancreatic bud in the embryo and varies greatly during development. An APD fistula is a rare and easily neglected complication. In this case report, the first symptom of the patient was postoperative abdominal pain and fever. He was eventually diagnosed with accessory pancreatic fistula combined with duodenal fistula. Such a case has not been reported in the literature.

Case Summary

A 66-year-old man was emergently hospitalized for abdominal pain. His preliminary diagnosis was perforation of the digestive tract. He developed fever and abdominal pain after emergency subtotal gastrectomy, followed by changes in the colour of the abdominal drainage fluid. An APD fistula and duodenal stump fistula were confirmed by drainage fluid amylase analysis, contrast fistulography and percutaneous transhepatic cholangial drainage (PTCD). After PTCD, nutritional management and drug treatment, the patient recovered well.

Outcome

We found and successfully cured a case of accessory pancreatic duct fistula combined with duodenal stump fistula.

[Not Available]

Background:

Erosion of the ductal lumen due to prolonged stagnation of pancreatic juice in the pancreatic ductal system leading to acute pancreatitis

Objective:

To study the incidence of accessory pancreatic duct and its clinical importance

Materials and Methods:

Fifty formalin fixed cadavers (41 males and 9 females; age range 35–60) from the departments of Anatomy, J. J. M. Medical College, Davengere, Karnataka and Chennai Medical College, Trichy, Tamilnadu, were utilized to study the incidence of accessory pancreatic duct by the dissection method. Pancreas was removed along with duodenum and dissected on its posterior surface to expose the main and accessory pancreatic ducts.

Results:

Regarding the types of accessory pancreatic duct, 26 (52%) out of 50 specimens belonged to the long type, 12 (24%) to the short type and 9 (18%) to the ansa pancreatica type. The embryonic type of the duct system was present in three (6%) specimens. The patency of the accessory pancreatic duct, which included patency of the long type, short type and ansa pancreatica type, showed that the accessory duct was patent in 29 (58%) out of 50 specimens. In 18 specimens (36%), the patency of the duct was absent. In three specimens (6%), the embryonic type of the duct system was present.

Conclusion:

The accessory pancreatic duct pattern helps in understanding the clinical correlation between pancreatico biliary pathology and associated clinical complications.

The endoscopic ultrasound-assisted Rendez-Vous technique for treatment of recurrent pancreatitis due to pancreas divisum and ansa pancreatica

Endoscopic treatment of pancreatic ductal malformations causing recurrent acute pancreatitis, such as pancreas divisum or ansa pancreatica, is mainly based on the sphincterotomy of the minor papilla. However, the technical complexity of conventional endoscopic retrograde cholangiopancreatography (ERCP) is increased in patients presenting anatomical variants like these and it may be unsuccessful. We report the case of a pancreas divisum combined with ansa pancreatica and describe the cannulation and sphincterotomy of the minor papilla using an ultrasound-assisted Rendez-Vous technique.

A pictorial review of diagnostic pitfalls of developmental anomalies and variants in pancreatic imaging

Developmental anomalies and anatomic variants of the pancreas vary widely, and most of them are encountered incidentally during radiologic evaluation. However, some of these anomalies and variants are potentially pathologic and may cause various clinical presentations in childhood or adulthood. The early identification of these entities in various imaging modalities including ultrasound, computed tomography (CT), and magnetic resonance (MR) imaging would be valuable in making correct diagnoses and, in turn, preventing unnecessary additional procedures. In order to differentiate these entities, it is fundamental to understand the embryologic development and normal anatomical structure of the pancreas. In this article, we review the embryology and normal anatomy of the pancreas, and diagnostic pitfalls of developmental anomalies and anatomic variants in various pancreatic imaging modalities.

Minor papilla endotherapy in patients with ventral duct obstruction: identification and management

BACKGROUND AND AIMS

Pancreatic duct (PD) cannulation via the major papilla may be compromised by downstream obstruction of the ventral PD from a stone or stricture. In patients with a patent accessory PD, cannulation of the minor papilla permits stenting or stone removal upstream of the ventral PD obstruction. Data on this technique are limited.

METHODS

University of Colorado Hospital and Maine Medical Center endoscopy databases were queried for ERCPs with minor papilla cannulation. Technical success was defined as deep cannulation of the minor papilla. Minor papilla endotherapy included sphincterotomy, stricture dilation, stenting, or stone treatment. Clinical improvement was designated as >50% reduction in pain or narcotic analgesia. Follow-up was obtained by chart review and telephone contact.

RESULTS

Over a 22-year period, 464 patients had minor papilla cannulation. Congenital and incomplete pancreas divisum were excluded, and 64 patients met study criteria. Technical success was achieved in 58 of 64 patients (91%). In patients with stones, 25 of 34 (74%) had clearance using endoscopic techniques. Median follow-up was 15.5 months. Twelve of 28 patients (43%) on chronic narcotic regimens reported a reduction in narcotic use by >50%, and 32 of 44 patients (73%) reached for discussion noted improved abdominal pain by >50%. Thirteen patients required surgery for symptom control.

CONCLUSIONS

In this multicenter experience, 15% of patients undergoing minor papilla cannulation had acquired a ventral PD obstruction. Access via the minor papilla to the upstream main PD for endotherapy and clinical improvement was achieved in most patients. Increased and early recognition of these intensive therapeutic options may enhance treatment options for this complex group of patients.

Clinical features of gallstone impaction at the ampulla of Vater and the effectiveness of endoscopic biliary drainage without papillotomy

BACKGROUND AND STUDY AIMS

Gallstone impaction at the ampulla of Vater is a critical condition, and the standard treatment is endoscopic papillotomy. However, the clinical features remain largely unclear, and some patients are reluctant to undergo papillotomy because of a bleeding tendency. The aim of this study was to clarify the clinical features of gallstone impaction at the ampulla of Vater and to examine the effectiveness of endoscopic biliary drainage without papillotomy.

PATIENTS AND METHODS

We retrospectively examined 30 patients who had undergone endoscopic treatment for gallstone impaction at the ampulla of Vater between 2010 and 2015.

RESULTS

According to the severity classification for acute cholangitis in the Tokyo Guidelines (TG13), the condition was mild in 8 patients, moderate in 14, and severe in only 8 (27 %), despite the stone impaction at the ampulla of Vater. Hyperamylasemia was observed in 18 patients (60 %); computed tomography (CT) revealed clear pancreatitis in 5 cases (17 %). Patients were classified into Group A (13 patients who received biliary drainage with papillotomy) and Group B (17 patients receiving biliary drainage without papillotomy). All patients in Group B had 1 or more types of hemorrhage risk. There were no differences between the 2 groups in the success rate of biliary drainage, the rate of elevated serum amylase the following day, or procedure-related complications. Serum amylase levels decreased the following day in all patients, even in Group B (including the 10 patients with hyperamylasemia and the 3 patients with clear pancreatitis on CT).

CONCLUSIONS

Even with stone impaction at the ampulla of Vater, typical clinical features of cholangitis and pancreatitis are relatively rare. Biliary drainage without papillotomy is acceptable for gallstone impaction at the ampulla of Vater.

Pancreatic Lipomatosis: An Extensive Pictorial Review

Pancreatic lipomatosis – also commonly called fat replacement – represents the most frequent benign pathologic condition of the adult pancreas. Most cases remain asymptomatic, and only some rare extreme degrees of lipomatosis or fat replacement may lead to exocrine pancreatic insufficiency.

The precise etiology of the entity remains unclear, and the condition has been found associated with several diseases comprising diabetes mellitus, metabolic syndrome, acquired or hereditary pancreatitis, alcoholic hepatitis, cystic fibrosis and condition comprising increasing age, body mass index, or more precisely visceral fat index, and use of steroid therapy. Numerous cases are also associated with condition compromising the permeability of the pancreas ductal system, such as intraductal calculus, pancreatic tumors, and congenital or experimental stenosis.

Uneven lipomatosis and fat replacement are also common presentations and responsible for the great diversity of imaging features. The reasons for uneven presentations are controversial and probably interweave embryologic or ductal hypotheses. Lipomatous pseudohypertrophy of the pancreas represents the most extreme situation of pancreatic lipomatosis and is considered, probably in a contestable way, as a rare, specific, and distinct entity.

We hereby present an extensive pictorial review of the broad spectrum of imaging features of this entity. The images are extracted from a compilation of cases collected in our department over more than a decade. We review and discuss the embryologic and ductal hypothesis, the differential diagnosis. Finally, we illustrate some unusual presentations and evolutions.

The angle of pancreaticobiliary junction correlates with acute pancreatitis: a magnetic resonance cholangiopancreatography study

OBJECTIVE

To study the correlation between the angle of the pancreaticobiliary junction (APJ) and the prevalence of acute pancreatitis using magnetic resonance cholangiopancreatography (MRCP).

MATERIALS AND METHODS

From February 2014 to October 2014, thirty two subjects with normal pancreas (group A) and 40 patients with acute pancreatitis (group B) who underwent MRCP were enrolled into our study. The type of biliary duct and main pancreatic duct joining the duodenal wall was reviewed and divided into V, B-P and P-B type. The V type is the pancreatic duct and biliary duct joining the duodenal wall without a common channel; the B-P type is the biliary duct draining into the pancreatic duct and forming a common channel; and the P-B type is the pancreatic duct draining into the biliary duct and forming a common channel. APJ was measured on MRCP. The correlation between the APJ and the prevalence of acute pancreatitis was analyzed.

RESULTS

The APJ in group A was smaller than in group B (51.45°±13.51° vs. 65.76°±15.61°, P<0.05). According to the type of biliary duct and main pancreatic duct joining the duodenal wall, the prevalence of acute pancreatitis in the V type and in the B-P type was higher than in the P-B type (12/17 vs. 10/29, or 18/26 vs. 10/29, respectively, all P<0.05), whereas there were no significant difference for the prevalence of acute pancreatitis between the V type and B-P type (P>0.05). The APJ were 59.32°±20.04°, 60.22°±11.06°, 57.13°±17.27°, respectively in V type, B-P type and P-B type joining of main pancreatic duct (P>0.05).

CONCLUSIONS

A larger APJ is related to a higher prevalence of acute pancreatitis.

Aberrant pancreatic ductal organisation: a case report

Anomalous pancreatic ductal system has always enthralled the anatomists, surgeons, gastroenterologists and radiologists alike. With the growing use of MRCP, ERCP and endoscopic and surgical procedures, the knowledge of anatomical aberrations of pancreaticobiliary tract becomes extremely important. Moreover, the anomalous pancreatic duct morphology may be responsible for atypical gastrointestinal complains. We report an exceptionally rare case of two accessory ventral pancreatic ducts opening separately into the common bile duct proximal to the hepato pancreatic ampulla. Concomitant occurrence of an ectopic major duodenal papilla, 3.8 cm distal to the pyloric end of stomach was also seen. Moreover, the accessory pancreatic duct and the minor duodenal papilla were absent. Clinical implications and embryological description of these rare anomalies are discussed. Awareness of such rare morphological variants can go a long way in assisting effective patient management.

Accessory pancreatic duct patterns and their clinical implications

CONTEXT AND OBJECTIVE

Accessory pancreatic duct (APD) designed to reduce the pressure of major pancreatic duct by forming a secondary drainage channel. Few studies have mentioned the variant types of accessory ducts and their mode of formation, some of these have a clear clinical significance. Present study is aimed to evaluate the possible variations in the APD and its terminations.

MATERIALS AND METHODS

Forty formalin fixed adult human pancreas with duodenum in situ specimens were studied by injecting 1% aqueous eosin, followed by piece meal dissection of the head of the pancreas from posterior surface. Formation, tributaries, relations, and the termination of the accessory pancreatic duct were noted and photographed.

RESULTS

Accessory ducts revealed 50% belonged to long type, 22.5% were of short and ansa pancreatica type each, and embryonic type of duct pattern was seen in 5% specimens. 75% of long type ducts showed positive patency with eosin dye, followed by ansa type (44.4%), and least patency was found in short type (22.2%). With regard to the patency of the accessory pancreatic ducts towards their termination, we found 52.5% of the accessory ducts and 5% of the embryonic type pancreatic ducts were patent and in 42.5% of the specimen the ducts were obliterated. In 85% of specimens the minor duodenal papillae was anterosuperior to the major papilla and superior to the major papillae in 10% of the cases, and in 5% minor papillae was absent. The average distance between the two papillae was 2.35 cm.

CONCLUSION

The knowledge of the complex anatomical relations of the gland with its duct, duodenum and bile ducts are essential for the surgeons and sinologists to plan and perform both the diagnostic as well as therapeutic procedures effectively.