Pancreatitis due to anomalous junction of the pancreaticobiliary ductal system

Endoscopic therapy in anomalous pancreatobiliary duct junction

BACKGROUND

Anomalous pancreaticobiliary duct junction is associated with bile duct strictures, pancreatitis, choledochal cysts, and biliary carcinoma. Limited data are available for outcomes of endoscopic therapy.

METHODS

Review of 7537 patients undergoing endoscopic retrograde cholangiopancreatography from 1988 to 1997 yielded 18 patients with anomalous pancreaticobiliary duct junction. Therapeutic responses were tallied by chart review and phone calls.

RESULTS

There were 13 women and 5 men, with a mean age of 36 years. Twelve patients had no ductographic evidence of pancreatitis and 6 had chronic pancreatitis. Seven had choledochal cysts. Fifteen patients (83%) underwent endoscopic biliary sphincterotomy, two of whom underwent repeat endoscopic biliary sphincterotomy for recurrence of symptoms. The other therapies included stent placement for benign biliary strictures in 5 patients, lithotripsy of pancreatic stones in 1 patient, and choledochal cyst removal in 4 patients. Three cases with malignant biliary strictures are excluded from endoscopic outcome studies. The 12 patients with pancreatitis had a mean of 2.0 episodes per year before any treatment. After endoscopic therapy 7 patients had no further episodes of pancreatitis, whereas 5 patients had further episodes, with a mean of one additional attack per year, over 3 years mean follow-up.

CONCLUSIONS

Patients with anomalous pancreaticobiliary duct junction have complex pathology associated with strictures, choledochal cysts, pancreatitis, and malignancies. Endoscopic therapy appeared to benefit 13 of 15 patients without malignant disease with elimination of or decreased frequency of pancreatitis. Endoscopic therapy appears to be a logical first step in the management of most symptomatic patients with anomalous pancreaticobiliary duct junction.

A case of intraperitoneal pancreas

A case of anomalous location of the pancreas is presented. In this case, head and a part of the body of the pancreas were found intraperitoneal. The pancreas was covered by the peritoneum within the omental bursa except its tail. Additionally, the anterior layer of the hepatogastric ligament turned over the hepatoduodenal ligament and continued behind the head of the pancreas together with the peritoneum which formed the posterior wall of the epiploic foramen (Winslow). The peritoneum also covered a part of the posterior surface of the body and directed to the right, forming a recessus just behind the pancreas.