Eastern Virginia Medical School Norfolk, VA, United States
Byung S. Yoo, MD1, Kevin V. Houston, MD2, Ankit Patel, MD3, Parth J. Parekh, MD1 1Eastern Virginia Medical School, Norfolk, VA; 2VCU Health System, Richmond, VA; 3George Washington University School of Medicine and Health Sciences, Norfolk, VA
Introduction: Annular pancreas (AP) is a congenital form of pancreatic anomaly which the pancreatic parenchyma encircles around the duodenum. The diagnosis of adult AP is rare as it largely remains asymptomatic. In this unique case we present a symptomatic AP complicated by gastric outlet obstruction (GOO) and treated with an endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ).
Case Description/Methods: A 58-year old woman with a past medical history of metastatic adenocarcinoma of the sigmoid colon status post sigmoid mass resection and currently undergoing chemotherapy presented with vomiting, abdominal fullness, and epigastric pain. Her labs were remarkable only for lipase of 2,047 U/L (normal range of 0-160 U/L). Subsequent imaging demonstrated an AP with resultant obstruction at the level of the second and third portion of the duodenum (Figure 1A). No radiographic evidence of pancreatitis was seen on CT. A barium swallow study confirmed a non-obstructive stricture extending from the second to the third part of the duodenum (Figure 1B), and the esophagogastroduodenoscopy revealed non-bleeding erosive gastropathy and duodenal stenosis. Due to the persistent symptoms, she underwent EUS-GJ. (Figure 1C, 1D, and 1E). Following the procedure, she was slowly advanced to a regular diet and was discharged home on post-procedure day 2.
Discussion: The current management of symptomatic AP focuses on bypassing the obstruction with surgical duodenostomy, gastrojejunostomy, and duodenojejunostomy. Alternative treatment modalities in order to bypass GOO have been a focus of investigation for patients with AP. EUS-GJ can be used for patients with GOO and complex anatomy who are poor surgical candidates. Technical and clinical success rates of 90% have been reported. Notably, the procedure can be technically challenging as the distal duodenal or proximal jejunal loop must be identified in order to create the anastomosis from the gastric body. Thus, this procedure should only be done by expert endoscopists due to this challenging technical aspect of EUS-GJ in addition to the relative rarity of the cases requiring utilization. To our knowledge, this case describes the first EUS-GJ for the treatment of GOO secondary to AP. EUS-GJ utilizing lumen apposing metal stent provides a less invasive method with low rates of complications in addition to immediate relief of the obstruction in GOO. We propose that the endoscopic treatment be further utilized in GOO due to AP.
Figure: Figure 1A. CT abdomen with contrast demonstrating annular pancreas (white arrows) Figure 1B. Stenosis of second and third part of duodenum with barium filling visualized in distal small bowel Figure 1C. Fluoroscopic image of navigating through duodenal stricture utilizing guided wire, and contrast was injected via a retrieval balloon in order to delineate the stricture Figure 1D. Needle puncture of the small bowel under ultrasonography Figure 1E. Visualization of the small bowel through the stent from the stomach
Byung Yoo indicated no relevant financial relationships.
Kevin Houston indicated no relevant financial relationships.
Ankit Patel indicated no relevant financial relationships.
Parth Parekh indicated no relevant financial relationships.
Byung S. Yoo, MD1, Kevin V. Houston, MD2, Ankit Patel, MD3, Parth J. Parekh, MD1. P2782 - Releasing the Shackle From Your Bowel: Endoscopic Ultrasound-Guided Gastrojejunostomy for Adult Annular Pancreas, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.