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| Discussion |
Case Report: A 25-year-old lady presented with mild epigastric pain on and off since two years. The pain had increased in intensity over the past few days and was non-radiating, non colicky and not associated with nausea or vomiting. There was no history of any other major illness.
On examination, there was mild tenderness in the epigastrium; however, no palpable lump was found. The patient’s vital parameters were stable.
Routine blood investigations were normal. Hemoglobin was 10.8 gm%, total WBC count was 6000/cumm, SGPT 55 IU/ml and SGOT 42 IU/ml.
Ultrasonographic findings:
On ultrasound of the abdomen, cholelithiasis and left crossed fused renal ectopia were found, The pancreatic head was found to be bulky. However, the echotexture of the head was normal.
CT findings:
Plain and contrast enhanced CT scans of the abdomen revealed a bulky head of pancreas with hyodense foci within. These were in contiguity with the duodenum. No pancreatic duct dilatation, calcification, peripancreatic stranding or intra or extra pancreatic fluid collections were found.
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MR findings:
MRI showed normal signal intensity of the pancreas, There was no intra or extra panctreatic collection. No peripancreatic stranding of fat plans was noted.
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DIAGNOSIS:
Annular pancreas with left crossed fused renal ectopia
DISCUSSION:
Annular pancreas is the second most common congenital anomaly of the pancreas after pancreas divisum. Annular pancreas is characterized by pancreatic tissue completely or incompletely surrounding the duodenum. In complete annular pancreas, patients usually present during the neonatal stage, however patient with incomplete or partial annular pancreas may not present until adulthood. In some instances, incomplete annular pancreas is detected incidentally. Annular pancreas more commonly affects males a nd, has a prevalence of one in 2,000 persons.
There are two types of annular pancreas - the extramural type and the intramural type. In the extramural type, the ventral pancreatic duct encircles the duodenum to join the main pancreatic duct.. In the intramural type, pancreatic tissue is intermingled with muscle fibers in the duodenal wall and small ducts drain directly into the duodenum.
Embryologically, the ventral pancreatic bud and the biliary system arise from the hepatic diverticulum, and the dorsal pancreatic bud arises from the dorsal mesogastrium. After clockwise rotation of the ventral bud around the caudal part of the foregut, there is fusion of the dorsal pancreas (located anterior) and ventral pancreas (located posterior). Finally, the ventral and dorsal pancreatic ducts fuse, and the pancreas is predominantly drained through the ventral duct, which joins the common bile duct (CBD) at the level of the major papilla. The dorsal duct empties at the level of the minor papilla.
Several theories regarding the etiology for the development of this entity have been proposed and are reviewed by Glazer and Margulis. They suggest that Baldwin ’s theory that the persistence of the left ventral bud—which normally atrophies during fetal development—leads to annular pancreas is the best explanation for this developmental anomaly.
In neonates, annular pancreas will manifest with features of duodenal obstruction. Complete duodenal obstruction typically occurs below the level of the ampula of Vater and presents as bilious vomiting that worsens with subsequent feeding. The most common abdominal radiographic finding is the double bubble sign, which is composed of gaseous dilatation of the stomach and proximal duodenum, with a paucity of bowel gas distally.Surgical repair of the annular pancreas with duodenojejunostomy or duodenoduodenostomy can relieve the obstruction and is commonly successful without complication.
Abnormalities associated with annular pancreas are intestinal malrotation, imperforate anus, esophageal atresia, duodenal atresia/stenosis, downs syndrome and cardiac anomalies.
Modalities available for diagnosis of annular pancreas are USG , CT , Barium studies and MRCP.
CROSSED FUSED RENAL ECTOPIA
Crossed fused renal ectopia is the fusion of both kidneys, with at least one kidney on the side opposite its normal location. The fusion of two kidneys is believed to result from one of two events:(1) Failure of the primitive nephrogenic cell masses to separate or
(2) Fusion of the two blastemas during their abdominal ascent.
Crossed fused renal ectopia is a congenital malformation. The patient's age at diagnosis varies depending on the secondary symptoms and complications. In the absence of associated complications and symptoms, the condition may be incidentally discovered on images obtained for reasons other than the evaluation of crossed fused kidneys as was the case in this patient. Many cases of crossed fused renal ectopia remain undiagnosed.
Abdominal and/or renal ultrasonography (US) is the preferred radiologic modality for detecting the condition.