The combination of annular pancreas and duodenum inversum presenting with delayed gastric emptying, pain, and feeding intolerance.

摘要

To the Editor: Annular pancreas is a congenital anomaly that consists of pancreatic tissue partially or completely encircling the descending portion of the duodenum (1). "Duodenal inversum" is an infrequent anomaly of duodenal rotation and fixation that is characterized by a clockwise rotation of the proximal duodenum (2). Duodenal inversum is an infrequent anomaly, and association with annular pancreas is an extremely rare occurrence. The authors present a case of annular pancreas with duodenal inversum observed in a 38-year-old patient who presented with duodenal obstruction that was treated by a partial Ladd's procedure and gasterojejunostomy. A 38-year-old woman developed chronic symptoms of crampy abdominal pain and fullness after eating, resulting in weight loss. She experienced a feeling of massive enlargement of her abdomen after meal, without vomiting. For the past 2 months, she had had practically continuous pain when taking even liquids. On admission, physical examination was essentially negative. Body weight was 41kg, and she appeared to be in a fair state of nutrition. Esophagogasteroduo-denoscopy with biopsies demonstrated only a large amount of bile in the stomach and moderate focal duodenitis in the first portion of the duodenum and duodenal stenosis in that area. An upper gastrointestinal barium-contrast study was performed and duodenal inversum was dignosed (Figure 1). A 10-month trial of medical management started, but her symptoms did not improve. The patient then opted for surgical exploration. At surgery, the duodenum was found to have an abnormal attachment to the ret-roperitoneum with mesenteric fixation bands causing a kink at the junction of the second and third portions of the duodenum. In the second portion of duodenum, we found a ring-shaped pancreatic tissue that encircled the duodenum, suggesting annular pancreas. The first portion of the duodenum was markedly dilated, as seen at upper gastrointestinal, and the third portion of the duodenum folded behind the second portion, in front of the hepatoduodenal ligament. The duodenum was mobilized and a partial Ladd's procedure and gasterojejunostomy was performed. Postoperatively, the patient recovered satisfactorily, and she has had no pain or feeding intolerance since the operation and has gained weight and tolerated solid foods well.