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Year : 2019  |  Volume : 6  |  Issue : 1  |  Page : 70-71

Complete annular pancreas with biliary ascariasis


Department of Radio Diagnosis, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India

Date of Submission26-Jul-2018
Date of Decision15-Aug-2018
Date of Acceptance16-Oct-2018
Date of Web Publication14-Feb-2019

Correspondence Address:
Mohd Ilyas
Department of Radio Diagnosis, Sher-I-Kashmir Institute of Medical Sciences, Srinagar - 190 011, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cjhr.cjhr_113_18

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How to cite this article:
Ilyas M, Bashir M, Choh NA, Shaheen FA. Complete annular pancreas with biliary ascariasis. CHRISMED J Health Res 2019;6:70-1

How to cite this URL:
Ilyas M, Bashir M, Choh NA, Shaheen FA. Complete annular pancreas with biliary ascariasis. CHRISMED J Health Res [serial online] 2019 [cited 2019 May 22];6:70-1. Available from: http://www.cjhr.org/text.asp?2019/6/1/70/252283



A 50-year-old male presented with the complaints of intermittent vomiting for the past 10–15 days with a history of epigastric pain. There was no complaint of fever, rigors, or chills. The vitals including pulse, blood pressure, and respiratory rate were within normal limits. Ultrasonography revealed a linear hypoechoic filling defect in the common bile duct (CBD) which was presumed to be a worm.

Magnetic resonance cholangiopancreatography (MRCP) was performed using 1.5 Tesla magnetic resonance imaging machine. The study revealed dilated CBD (9 mm) with a linear hypointense elongated filling defect in its lumen [Figure 1]. The pancreatic head was seen to be completely surrounding the second part of the duodenum with no differentiation of the duodenal wall from the pancreatic tissue [Figure 2]. The MRCP findings were suggestive of the complete annular pancreas and biliary worm infestation.
Figure 1: Coronal T2-weighted magnetic resonance image showing a linear hypointense structure in the common bile duct which was later proven to be common bile duct worm (ascaris)

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Figure 2: Axial magnetic resonance images show the classic appearance of the intramural type of annular pancreas wherein the duodenum is encircled by the pancreatic tissue and a filling defect in the common bile duct

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Endoscopic retrograde cholangiopancreatography was performed to retrieve the worm from CBD which was found to be Ascaris. The patient is currently symptom-free. The symptoms of the patient relieved and it was confirmed that those were due to biliary ascariasis. The annular pancreas being an incidental finding was mentioned in the patient records to be kept under follow-up.

Annular pancreas refers to the encircling of the second part of the duodenum by the ventral anlage of the pancreas due to its incomplete rotation. Two types of the annular pancreas have been described as follows: intramural and extramural. When the ventral pancreatic duct encircles the duodenum before joining the dorsal pancreatic duct, it is called extramural annular pancreas. However, in the intramural type, muscle fibers of the duodenal wall and the pancreatic tissue get intermingled and small pancreatic ducts directly drain into the duodenum,[1] as shown in [Figure 2]. In pediatric patients, classic findings on conventional radiography include the classic double-bubble sign. CT and MR imaging demonstrate the pancreatic tissue encircling the second part of the duodenum.[2]

The presenting symptoms in the extramural annular pancreas are those of high gastrointestinal obstruction whereas in the intramural type, symptoms are those of duodenal ulceration. The treatment for extramural type is surgical and usually a bypass procedure while that for the intramural type with duodenal ulceration is subtotal gastrectomy with or without vagotomy.[3]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mortelé KJ, Rocha TC, Streeter JL, Taylor AJ. Multimodality imaging of pancreatic and biliary congenital anomalies. Radiographics 2006;26:715-31.  Back to cited text no. 1
    
2.
Borghei P, Sokhandon F, Shirkhoda A, Morgan DE. Anomalies, anatomic variants, and sources of diagnostic pitfalls in pancreatic imaging. Radiology 2013;266:28-36.  Back to cited text no. 2
    
3.
Rondelli F, Bugiantella W, Stella P, Boni M, Mariani E, Crusco F, et al. Symptomatic annular pancreas in adult: Report of two different presentations and treatments and review of the literature. Int J Surg Case Rep 2016;20S:21-4.  Back to cited text no. 3
    


    Figures

  [Figure 1], [Figure 2]



 

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