Post written by Evan L. Fogel, MD, MSc, from the Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA.

Annular pancreas is a rare congenital anomaly most often diagnosed in children, but it may be seen in adults as well. It is an entity in which pancreatic tissue either partially or completely encircles the duodenum. The focus of the study was to describe the findings on endoscopy and pancreatography for patients with annular pancreas undergoing ERCP.

Most of the existing literature on annular pancreas includes very small case series or case reports. Previously, annular pancreas was felt to be very rare, with estimates of annular pancreas occurring in one in 20,000 live births, but more recent estimates suggest that this may be as frequent as one in 1000 births. Anecdotally, we have noted that completing ERCP can be quite challenging in patients with both annular pancreas and pancreas divisum. Our goal was to shed more light on the ERCP findings in patients with annular pancreas and determine whether technical success rates differ from patients with “normal” pancreas anatomy (ie, patients without annular pancreas).

From 1994 to 2016, we identified 46 patients with annular pancreas who had undergone ERCP at our institution. These ERCPs were performed for a variety of indications, most commonly pancreatitis and pancreatobiliary pain. Prior foregut surgery was found in 11% of patients. We found that a duodenal narrowing or ring was present in 85% of patients; however, only 4% of patients had retained gastric contents. ERCP was technically successful in 91% of patients on the first attempt, and the remaining patients had technically successful ERCP on the subsequent attempt. Consistent with prior reports of far fewer patients, we found that a significant number of patients (46%) had concurrent pancreas divisum. Of the 21 patients with pancreas divisum, the location of the minor papilla was reported in 16 patients, and this was found to be quite variable at the junction of the first and second portions of the duodenum; just proximal to the annular ring; on the annular ring itself; just below or distal to the annular ring; or in the usual position just proximal to the major papilla in the 1 o’clock position. This variable location often made minor papilla cannulation more challenging, and our technical success rate with minor papilla cannulation at the index ERCP was only 86% or 18 of 21 patients. We did succeed at a second attempt in the remaining 3 patients. Interestingly, we found that approximately one-third of the entire group of 46 patients had pancreatographic findings consistent with chronic pancreatitis on the index ERCP. Since this was a retrospective study encompassing over 20 years of ERCP at a high-volume center, we were not able to collect any meaningful data regarding outcomes from endoscopic therapy in this group.

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