SURGICAL INTERVENTION FOR ANNULAR PANCREAS IN A 16-YEAR-OLD: A RARE CASE HIGHLIGHTING THE ROLE OF LAPAROSCOPIC DUODENODUODENOSTOMY

Document Type

Conference Proceeding

Publication Date

7-17-2025

Publication Title

J Gen Intern Med

Keywords

nonsteroid antiinflammatory agent, proton pump inhibitor, abdominal pain, adolescent, adult, age distribution, annular pancreas, backache, body weight gain, body weight loss, case report, clinical article, comorbidity, complication, conference abstract, conservative treatment, diagnosis, drug therapy, epigastrium, esophagogastroduodenoscopy, female, gastritis, human, laparoscopy, nausea, nausea and vomiting, nephrolithiasis, newborn, postoperative pain, prevalence, right upper abdominal quadrant, scar tissue, surgery, vomiting

Abstract

CASE: A 16-year-old female with a history of nephrolithiasis and gastritis presented to the clinic with back pain, abdominal pain, and nausea. She was diagnosed with nephrolithiasis and was treated appropriately. However, over the course of a few months, her symptoms returned, and the pain transitioned into a sharp, waxing and waning pain, localized to the right upper quadrant (RUQ) of the abdomen and epigastrium with no evidence of nephrolithiasis. She underwent an esophagogastroduodenoscopy (EGD), which demonstrated severe gastritis and an annular pancreas with dilatation of the proximal duodenum. It was determined her symptoms were likely due to NSAID induced gastritis and not the annular pancreas, as the duodenum did not exhibit significant scarring. Despite appropriate treatment of gastritis with a proton pump inhibitor, her symptoms of nausea and RUQ abdominal pain persisted. She underwent a second EGD which showed persistence of the annular pancreas, causing narrowing of the second segment of the duodenum with subsequent dilatation of the duodenal bulb and first segment. She had a nasojejunal tube (NJT) placed to address her weight loss due to the constant nausea, and she was scheduled for a laparoscopic duodenoduodenostomy (LDD). However, she continued to have several bouts of emesis, leading to displacement of her NJT. She was admitted to the hospital for reinsertion of her NJT, and her morning tube feeds continued without difficulty. After meeting weight gain requirements, it was decided to proceed with operative management earlier than expected due to her constant symptoms, and she underwent the procedure with no complications. Since the operation, she has not experienced any symptoms of nausea, vomiting, or abdominal pain. IMPACT/DISCUSSION: Annular pancreas is a rare congenital anomaly, with a prevalence of approximately 3.4/100,000, typically diagnosed in neonates or adults aged 20 to 50 years. Diagnosis can be challenging when there are overlapping co-morbidities as well as a delayed onset of symptoms. Conservative management including NJT feeding and medication treatment can be used to manage symptoms. However, in severe cases with persistent symptoms, surgical intervention may be required. LDD is an uncommon procedure in adolescents to treat annular pancreas, with a 5-10% repair rate, primarily due to the technical precision required and the challenges posed by smaller anatomical structures. Regardless, this approach offers significant benefits, including reduced postoperative pain and faster recovery, making it a valuable option in carefully selected cases. CONCLUSION: This case emphasizes the need to recognize atypical presentations of annular pancreas in adolescents, especially those that do not fit a bimodal age distribution of diagnosis. It highlights how overlapping, nonspecific symptoms, and variable intermittent symptom pain can delay diagnosis. Clinicians must maintain a high index of suspicion to assess the suitability of LDD in managing delayed-onset cases.

Volume

40

First Page

S12

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