Ventral pancreatitis defined on MRI

Ventral pancreatitis, pancreatitis localized in the embryologic ventral pancreas, is rare. To date, only three well documented reports of ventral pancreatitis have been reported in the English-language literature. All three were associated with pancreas divisum. This report presents a patient suspected to have ventral pancreatitis on endoscopic retrograde cholangiopancreatography, confirmed by magnetic resonance imaging. (Received Nov. 20, 1997; accepted May 22, 1998)     

Prevalence and clinical evolution of isolated ventral pancreatitis in alcoholic chronic pancreatitis

BACKGROUND: The role of pancreas divisum in chronic pancreatitis is controversial. Ductal changes limited to the pancreatic ventral duct (isolated ventral pancreatitis) have only been described as isolated case reports. METHODS: In a cohort of 542 patients with chronic pancreatitis we determined the frequency of ventral chronic pancreatitis among patients with pancreas divisum and analyzed the clinical presentation of 10 patients with isolated ventral alcohol-induced pancreatitis compared with 10 patients with isolated dorsal alcohol-induced pancreatitis and 30 patients with chronic pancreatitis and without pancreas divisum. Magnetic resonance pancreatography under secretin stimulation was used to evaluate the status of the dorsal pancreatic duct in some patients during follow-up. RESULTS: We identified 62 (11.4%) patients with pancreas divisum and 16 (2.9%) patients with incomplete pancreas divisum. The ventral duct was affected by chronic pancreatitis in 74% of these patients. Isolated ventral or dorsal duct alterations were identified in 14% and 26%, respectively, of patients with pancreas divisum. Patients with isolated ventral pancreatitis had pain symptoms similar to those of the two other groups but had no endocrine or exocrine insufficiency on initial presentation. After a mean follow-up of 44 months, 83% of patients studied with isolated ventral pancreatitis developed alterations of the dorsal ductal part of the gland. CONCLUSION: We conclude that isolated ventral alcohol-induced pancreatitis is one of the first manifestations of generalized pancreatic disease where the anatomic factor of pancreas divisum plays only a marginal role.     

A case of colon obstruction developed during the recovery period of acute pancreatitis]

Complications of acute pancreatitis usually occur in pancreas and its contiguous organs. The prevalence of colonic invasion is rare, however, the consequence is fatal, with mortality above 50%. The initial symptoms and onset times are variable and major affected sites are transverse colon and splenic flexure. The spread of inflammatory exudates into the colon is the main mechanism of colonic invasion. If the colonic stenosis develops, it is necessary to manage it surgically. We report a case who arrived at the hospital with watery diarrhea and abdominal distension in the recovery period of acute alcoholic pancreatitis and was diagnosed as a colonic obstruction in the splenic flexure. The patient underwent loop ileostomy instead of the resection of the lesion because of severe adhesion around the splenic flexure. The patient died due to sepsis 5 days after the operation.     

Herniation of colon following transhiatal esophagectomy.

We report a 38-year-old man with intestinal obstruction following transhiatal esophagectomy for carcinoma esophagus; it occurred secondary to herniation of the transverse colon through the esophageal hiatus into the mediastinum. The patient is asymptomatic after reduction of the hernia and repair of the disphragmatic hernia.     

Isolated colonic hernia through the esophageal hiatus

We report on a 75-year-old woman with an isolated colonic hernia through the esophageal hernia. The patient had suffered from cough, palpitation and dyspnea. A chest X-ray showed a colon loop gas in the mediastinum. Simultaneous barium swallow and enema showed the herniation of the only transverse colon into the mediastinum and displacement of the distal esophagus by the migrated colon. The patient underwent an open-mesh cruroplasty and a Hill's posterior gastropexy. The postoperative clinical course was uneventful. The patient has cessation of the symptoms. To our knowledge, there are only five reports presenting patients with isolated colonic hernia through the esophageal hiatus, including our case.     

A case of colon obstruction developed as a complication of acute pancreatitis]

In acute pancreatitis, colonic complications such as mechanical obstruction, ischemic necrosis, hemorrhage, and fistula are rare but their outcomes are fatal. It is known that colonic obstruction in acute pancreatitis is more likely found in splenic flexure and transverse colon caused by severe inflammation of body and tail of pancreas leading to pressure necrosis. A 43-year-old man presented with abdominal distension lasting for 2 weeks. The patient had been admitted to our institution 6 weeks prior to the current admission, and the abdominal CT scan performed during the first admission revealed the pancreatic enlargement with peri-pancreatic fatty infiltration and fluid collection. At that time he was diagnosed as acute pancreatitis. The conservative management resulted in clinical improvement so that the patient was discharged. Upon the second admission, abdominal CT scan revealed multiple pseudocysts in the tail portion of pancreas with concominant wall thickening and narrowing of the proximal descending colon, and a dilatation of the bowel proximal to the splenic flexure. An obstruction of the descending colon as a complication of acute pancreatitis was suspected and the patient underwent left hemicolectomy. Abdominal distension was relieved after the operation and he was discharged on the 15th hospital days.     

Unusual type of left paraduodenal hernia caused by a separated peritoneal membrane

Internal hernias are an uncommon cause of intestinal obstruction, with left paraduodenal hernia being the most frequent of these. Computed tomography (CT) with contrast media is advantageous for the clinical workup of suspected paraduodenal hernias. Here, we report a case of an unusual paraduodenal sac formed by a peritoneal membrane between the transverse and the descending colon, which entrapped the proximal jejunum, causing intestinal obstruction. Preoperative CT demonstrated a cluster of jejunal loops between the stomach and pancreas, and showed that the inferior mesenteric vein was laterally displaced. Received: January 15, 2001 / Accepted: May 11, 2001 Reprint requests to: T. Nishida     

Isolated ventral pancreatitis in a patient with pancreas divisum

A previously healthy 22-yr-old woman was found to have chronic pancreatitis restricted to the ventral pancreas in association with pancreas divisum. When conservative treatment failed, sphincteroplasty of both papillae was performed with good results. This well-documented case represents a clear exception to the commonly held concept that obstruction of the dorsal duct is the essential pathogenic factor in the development of pancreatitis associated with pancreas divisum. The importance of visualizing both the dorsal and ventral pancreatic ducts to direct therapy for patients with idiopathic pancreatitis is discussed. Theories of the pathogenesis of concomitant pancreatitis and pancreas divisum are reviewed.     

Chronic pancreatitis with pancreas divisum treated with pylorus-preserving pancreatoduodenectomy: a case report

Pancreas divisum, the most common congenital variant of pancreatic ductal anatomy, occurs when the ventral and dorsal pancreatic-buds fail to fuse. Herein, we report on a 42-year-old male suffering from chronic pancreatitis with pancreas divisum. Magnetic resonance cholangiopancreatography confirmed this diagnosis. A pylorus-preserving pancreatoduodenectomy was then performed. Pathological examination of the pancreas demonstrated chronic pancreatitis without malignancy. The postoperative clinical course was uneventful, and the patient was discharged 10 days after surgery.     

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.     

Acute pancreatitis caused by a voluminous umbilical hernia. Case report

A 65 year old woman, who had a giant umbilical hernia since more than 30 years, was admitted for a transitory cerebrovascular ischemia. During her stay, she presented an episode of acute pancreatitis localized in the head of the pancreas. All current causes of acute pancreatitis were ruled out, especially alcoholism and gallstones. Endoscopic retrograde cholangio-pancreatography performed in the patient lying on the left side demonstrated localization of the antrum and the duodenum with the head of the pancreas into the umbilical hernia. It seems clear that the giant umbilical hernia caused a progressive and intermittent passage of the head of the pancreas through chronic traction on the ligament of Treitz and acute pancreatitis by incarceration. At our knowledge, this mechanical cause of acute pancreatitis was not yet described in the literature.     

Multiple neuroendocrine tumors of the pancreas associated with pancreas divisum

Pancreas divisum is the most common congenital anomaly of the pancreas, characterized by missing fusion of the ventral and dorsal pancreatic duct. It may cause pancreatitis, but is rarely associated with malignancy.We report herein for the first time the rare association, in a symptomless patient, of multiple neuroendocrine tumors of the pancreas with pancreas divisum and a failure of the exocrine system. Diagnosis was made incidentally by routine abdominal ultrasound. Laboratory examinations and a fine-needle aspiration revealed the neuroendocrine nature of the tumor. Spleen-preserving left pancreas resection was performed, with evidence of multiple neuroendocrine tumors of the pancreas with the typical histological characteristics. Eighteen months later the patient is still free of tumor burden.     

Isolated ventral pancreatitis in an alcoholic with pancreas divisum

An alcoholic with no history of clinical pancreatitis was found to have pancreas divisum and marked changes of chronic pancreatitis isolated to the ventral pancreas. Pancreas divisum has been suggested to cause recurrent pancreatitis in some patients. Gross and histologic changes of pancreatitis in only the dorsal pancreas of surgically resected specimens from patients with pancreas divisum is thought to support the concept that obstruction at the minor papilla produces dorsal pancreatitis. Alternative explanations for the occurrence of segmental pancreatitis and the possible synergistic role of ethanol and bile are reviewed.     

Acute pancreatitis affecting the transverse colon

Summary A case is reported in which a lesion of the transverse colon was caused by acute pancreatitis. A deformity in the hepatic flexure of the transverse colon was noted from barium-enema examination and it simulated a segmental ulcerative colitis or a carcinoma. This deformity was attributed to an inflammatory mass with fat necrosis, which resulted from corrosive enzymes released from the pancreas.The opinions or assertions contained herein are the private ones of the writers and are not to be construed as official or as reflecting the views of the Bureau of Medicine and Surgery of the Navy Department or the naval service at large.The authors wish to thank Frances H. Atkinson, B.A., R.R.L., for technical editing.     

Routes of spread of pathogens into the pancreas in a feline model of acute pancreatitis.

The routes of spread of pathogens into the pancreas in acute pancreatitis were investigated. Four experiments were performed: (1) cats with and without acute pancreatitis were given 10(7) Escherichia coli (E coli) intravenously, (2) in cats with acute pancreatitis 10(8) E coli was placed in the colon. In half of them the colon was then enclosed in an impermeable bag to prevent transmural spread. (3) E coli (10(4)) was placed in the pancreatic duct in cats with and without acute pancreatitis. (4) In cats with acute pancreatitis 10(5) E coli was placed in the gall bladder. In half of them the common bile duct was ligated to prevent biliary-pancreatic reflux. After 24 hours, intravenous E coli infected the pancreas in six of nine cats with acute pancreatitis and three of 10 controls. After 72 hours E coli spread to the pancreas from the colon in six of nine cats with acute pancreatitis. This was prevented by enclosing the colon in an impermeable bag (p = 0.02). In five of six cats with acute pancreatitis and five of six controls E coli placed in the pancreatic duct colonised the pancreas within 24 hours. Pancreatic colonisation from the gall bladder occurred in five of six cats with a patent common bile duct and in three of six with an obstructed common bile duct. In conclusion, in cats E coli can spread to the pancreas by the blood stream, transmurally from the colon, and by reflux into the pancreatic duct.     

Pancreatitis associated with Crohn''s disease: a premalignant state for cystadenocarcinoma of pancreas?

We report a 74-yr-old woman with Crohn's disease and acute pancreatitis who, 3 yr after resolution of the latter, developed cystadenocarcinoma of the pancreas. No drug, toxin, or other etiologies including contiguous duodenal involvement were identified as responsible for the pancreatitis, suggesting that pancreatitis was an extraintestinal manifestation of her Crohn's disease. Could Crohn's-associated pancreatitis be a premalignant state for cystadenocarcinoma of the pancreas?     

Pancreas divisum does not modify the natural course of chronic pancreatitis

Background Pancreas divisum is the most common congenital variant of the pancreas; however, its clinical significance remains controversial. The purpose of our study was to determine the role of pancreas divisum in the development of chronic pancreatitis. Methods We compared the clinical presentation, morphological findings, and course of disease of 30 patients with chronic pancreatitis associated with pancreas divisum (there was coexisting chronic alcohol abuse in 18 cases) to those of 57 patients with chronic pancreatitis and no evidence of pancreas divisum (15 with nonalcoholic pancreatitis and 42 with alcoholic pancreatitis). Results Sex distribution, age at onset of disease, clinical presentation, course of disease, and frequency of complications were not affected by the presence of pancreas divisum. Although the etiology of pancreatitis in patients with pancreas divisum may be attributed to impaired drainage of the majority of the gland through the minor papilla, we observed a relatively low frequency of isolated dorsal duct involvement in our patients irrespective of alcohol use (25% and 28% in patients with and without a history of alcohol abuse, respectively). However, involvement of the ventral duct was commonly observed (75% and 72%, respectively). Conclusions The presence of pancreas divisum in our study did not modify the natural course of chronic nonalcoholic or alcoholic pancreatitis. Pancreas divisum is not likely to play a dominant role in the etiopathogenesis of chronic pancreatitis.     

Pancreatic endocrine carcinoma presenting with gastric varices derived by left-sided portal hypertension: a case report

We herein report a 71-year-old man with pancreatic carcinoma presenting as gastric varices caused by an obstruction of the splenic vein compressed by the tumor, which also invaded the spleen, stomach, transverse colon, left kidney, and left adrenal gland. A complete resection of distal pancreatomy and lymph node dissection with splenenctomy, left adrenalectomy, left nephrectomy, and partial resection of transverse colon and stomach were performed. After the resection, the gastric varices completely disappeared without any interventional therapy. The gastric varices observed in this case were considered to be derived from left-sided portal hypertension secondary to splenic vein occlusion, which is an uncommon complication mostly associated with pancreatitis and pancreatic carcinoma. Now that 17 months have passed after his operation, the patient is alive and in satisfactory condition without any signs of recurrence.     

Colonic carcinoma presenting as strangulated inguinal hernia: report of two cases and review of the literature

Inguinal hernia and colonic carcinoma are common surgical conditions, yet carcinoma of the colon occurring within an inguinal hernia sac is rare. Of 25 reported cases, only one was a perforated sigmoid colon carcinoma in an inguinal hernia. We report two cases of sigmoid colon carcinoma, one of which had locally perforated. Each presented within a strangulated inguinal hernia. Oncologically correct surgery in these patients presents a technical challenge.     

Pancreas divisum is a probable cause of acute pancreatitis: a report of 137 cases

The incidence of pancreas divisum (PD) was evaluated in a retrospective series of 1,825 successful consecutive ERCPs. One hundred thirty-seven pancreas divisums (7.5%) were found in 80 males and 57 females at a mean age of 49.2 years. The ventral ducts were visualized in 82.5% and the dorsal ducts in 74.1% of attempted cannulations of the minor papilla. Pancreas divisum was significantly more frequent in patients presenting with acute idiopathic pancreatitis (50.0%) or acute biliary pancreatitis (23.7%) than in controls or in the general population. This difference was not found in acute pancreatitis due to other etiologies. Acute pancreatitis associated with PD is generally recurrent, is not severe, but may be complicated by necrotic pseudocysts. The frequency of PD was also significantly increased in patients with gallbladder stones but not with common bile duct stones. In other pathological groups--chronic pancreatitis and pancreatic cancer--the frequency of pancreas divisum was not statistically different from that observed in controls and/or in the general population. We conclude that on a statistical basis, PD is a probable cause of acute pancreatitis, especially in its idiopathic recurrent variety, and that its frequency is increased in patients with gallbladder stones.