Gastrointestinal Imaging Original Research

Sandrasegaran et al.
Annular Pancreas in Adults

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Gastrointestinal Imaging
Original Research

Annular Pancreas in Adults

Kumaresan Sandrasegaran1
Aashish Patel1
Evan L. Fogel2
Nicholas J. Zyromski 3
Henry A. Pitt 3
Sandrasegaran K, Patel A, Fogel EL, Zyromski NJ,
Pitt HA

Keywords: annular pancreas, CT, MRI, secretin

DOI:10.2214/AJR.08.1596
Received July 27, 2008; accepted after revision
January 22, 2009.
1
Department of Radiology, Indiana University School of
Medicine, 550 N University Blvd., UH 0279, Indianapolis,
IN 46202. Address correspondence to K. Sandrasegaran
(ksandras@iupui.edu).
2
Division of Gastroenterology, Department of Medicine,
Indiana University School of Medicine, Indianapolis, IN.
3
Department of Surgery, Indiana University School of
Medicine, Indianapolis, IN.

AJR 2009; 193:455460

0361803X/09/1932455
American Roentgen Ray Society

AJR:193, August 2009

OBJECTIVE. The purpose of this study was to review the CT, MRI, and ERCP findings
of annular pancreas in adults.
MATERIALS AND METHODS. A search of the radiology and ERCP databases at our
institution for cases of annular pancreas in adults yielded the records of 42 patients who underwent 29 ERCP, 22 CT, and 13 MRI examinations. The CT and MR images were reviewed
by two readers, and consensus agreement was reached regarding the shape of the pancreas,
anatomic configuration of the ducts, and presence of disease. In addition, the degree of encirclement of the second part of the duodenum by the pancreatic head was evaluated in 24
patients with the CT or MRI finding of annular pancreas and in 30 control patients who were
found not to have annular pancreas at ERCP.
RESULTS. Nine of 24 (37.5%) cases of annular pancreas detected with CT or MRI did not
have a radiologically complete ring of pancreatic tissue surrounding the second part of the duodenum. Three of the nine patients (33%) with radiologically incomplete annular pancreas and six
of the 15 patients (40%) with complete annular pancreas had gastric outlet obstruction (p = 0.75).
The presence of pancreatic tissue posterolateral to the second part of the duodenum had a high
sensitivity (92%) and specificity (100%) for the presence of annular pancreas. The rates of pancreas divisum (37%) and chronic pancreatitis (48%) were high in this cohort.
CONCLUSION. Annular pancreas can be diagnosed without the finding of a radiologically complete ring of pancreatic tissue. A crocodile jaw configuration of pancreatic tissue is
suggestive of the presence of annular pancreas.

nnular pancreas is an uncommon

congenital anomaly. Findings in
an autopsy series indicated a
prevalence of 515 cases per
100,000 adults [1]. This number may not indicate the true prevalence because duodenal
dissection is not routinely performed during
autopsy. Studies of ERCP, however, have
shown a prevalence of 1 in 250, or 400 cases
per 100,000, adults [2]. Bias likely exists in
such series because the cohort would have a
high probability of pancreatic disease. The
true prevalence of annular pancreas is unknown but may lie between the values found
in the autopsy and ERCP studies.
Annular pancreas is well known as a neonatal condition causing duodenal obstruction, sometimes in conjunction with other
congenital abnormalities, including Down
syndrome [3]. A review [4] of 103 cases suggested that annular pancreas is as common
among adults as it is among children, the age

at detection in adults usually being in the

third to sixth decade of life. The presentation
in adults differs from that in children. Congenital anomalies and duodenal obstruction
are the predominant features in children,
and pancreatitis is the main presentation in
adults [4]. Our experience since the advent of
MDCT and high-quality MR cholangiopancreatography (MRCP) suggests that annular
pancreas is more common than previous reports suggest, particularly if radiologically
incomplete annular pancreas (herein called
incomplete annular pancreas) is included. In
many cases, the radiologist is often the first
to make the diagnosis of this entity. A review
of the English-language medical literature
revealed that the CT and MRI findings on 25
adult patients with complete annular pancreas have been previously described, mostly in
case reports [521]. We review the largest, to
our knowledge, radiologic series of annular
pancreas in adults.

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Sandrasegaran et al.

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Materials and Methods

Patients
Institutional review board permission was obtained with waiver of informed consent for this
retrospective HIPAA-compliant study. Review of
endoscopic and radiologic databases from January 2002 to December 2006 revealed the cases
of 42 patients with annular pancreas whose CT,
MRI, or ERCP images were available for review
on a PACS. This group consisted of 24 patients
who underwent CT, MRI, or both and 29 patients
who underwent ERCP. Figure 1 shows the methods of identification of annular pancreas in this
cohort. All cases of radiologically incomplete annular pancreas were diagnosed by means of visualization of an annular pancreas at ERCP (n = 6)
or surgery (n = 3). For evaluation of the normal
morphologic features of the pancreatic head at CT
or MRI, 30 control patients consecutively registered from July to December 2006 who had ERCP
evidence of anatomically normal ducts and no history of pancreatitis also were analyzed. These patients had undergone ERCP for evaluation of nonspecific upper abdominal pain.

Imaging Studies
Images from a total of 22 CT and 13 MRI preoperative examinations of 24 patients with annular pancreas were evaluated. Eleven patients underwent both CT and MRI. In the cases of patients
who underwent more than one CT examination,
the first study performed with IV contrast administration was analyzed. CT studies were performed with a 4- or 16-MDCT scanner (MX8000
and Brilliance-16, Phillips Medical Systems). CT
parameters depended on the scanner and size of
the patient. Tube potential varied between 100 and
140 kVp, and the range of tube currenttime products was 220425 mAs. Between 120 and 150 mL
of iopamidol (Isovue 300, Bracco) was administered IV for all CT examinations. The effective
slice widths were 6.5 and 5 mm for the 4- and 16MDCT scanners, respectively, with longitudinal
reconstruction of 3.0 and 2.5 mm.
The CT examinations of the patients with a
normal pancreas also were performed with IV
contrast administration. The rate of IV contrast injection was 25 mL/s. Sixteen of the 22 CT examinations were performed with 500750 mL of oral
2% diatrizoate meglumine and diatrizoate sodium
solution (Gastrografin, Bracco Diagnostics). Four
studies were performed with 500 mL of water as a
neutral oral contrast agent. The other studies were
performed without oral contrast enhancement.
The MRI studies were performed with a 1.5-T
system (Signa, GE Healthcare). The protocol included T1-weighted in-phase and out-of phase axial images; T2-weighted coronal turbo spin-echo

456

images; and T1-weighted fat-suppressed volumetric acquisition in the unenhanced, arterial, venous, and 3-minute phases of enhancement after
administration of 20 mL of gadopentetate dimeglumine (Magnevist, Bayer HealthCare) at 12
mL/s. All patients had fasted 46 hours before
imaging and received 300 mL of ferumoxsil oral
suspension (GastroMark, Mallinckrodt Medical)
as a negative oral contrast agent. Two-dimensional 4-cm slab MRCP and 3D navigator-corrected
MRCP images were acquired at all MRI examinations. Secretin-enhanced MRCP according to a
previously published protocol [22] was performed
at all MRI examinations.

Review of CT, MRI, and ERCP Findings

Two radiologists blinded to indication, clinical progress, and findings at ERCP evaluated the
CT and MR images in consensus using a PACS.
The window settings varied according to whether CT or MR images were being reviewed. The
typical window setting for CT was a level of 30
HU and window width of 400 HU. These settings
were varied to optimally show the duodenum and
pancreas. PACS features such as zoom and pan
were used to assess the relevant anatomic structures. The degree of encirclement of the duodenum by the pancreas, anatomic configuration of
the ducts, presence of gastric or duodenal distention or chronic pancreatitis, and the caliber of extrahepatic bile ducts were recorded. A consensus
decision was made about the presence of incomplete or complete annular pancreas.
CT findings were compared with MRI and
MRCP findings. Secretin-enhanced and non-secretin-enhanced MRCP images also were compared. Comparisons of CT and MR images or secretin- and non-secretin-enhanced MRCP were
made on a three-point scale of superior quality,
inferior quality, or no difference in diagnosis by
two reviewers in consensus. It was not possible to
blind the reviewers to secretin-enhanced versus
non-secretin-enhanced images because the former
was a dynamic sequence of 21 images in which
gradual filling of the duodenum occurred as a result of the exocrine response to secretin [22]. The
CT scans of the control patients were reviewed at
a subsequent session for degree of encirclement of
the duodenum by the pancreatic head. The reviewers knew that these patients did not have a diagnosis of annular pancreas.
The findings from the prospectively recorded ERCP database were collected. This database
had an extensive worksheet on each patient that
detailed the presence and severity of pancreaticobiliary and upper gastrointestinal findings. The
ERCP images also were reviewed with the PACS.
The ERCP database contained more information

than the available images in the PACS. For example, static PACS images would not have included
endoscopic findings or real-time findings not captured during an ERCP procedure.

Statistical Analysis
Statistical analysis was performed with MedCalc software (version 9.2, MedCalc). For the
small numbers of patients in subgroups, such as
the comparison of CT and MRI, formal tests were
not applied.

Results
Patients
The study group consisted of 29 women
and 13 men (mean age, 51 years; range, 20
86 years). The main indications for ERCP,
CT, and MRI were abdominal pain in 16
cases, gastric outlet obstruction in nine, abnormal results of liver function tests in one
case, preoperative assessment of known pancreatic cancer in two cases, preoperative assessment of intraductal mucinous pancreatic tumor in one case, and investigation of
a pancreatic head mass seen on images obtained at a referring institution in four cases.
In nine cases, the finding of annular pancreas was incidental in patients undergoing imaging for cancer staging (renal in two cases,
melanoma in one case), hepatocellular cancer screening for a patient with cirrhosis in
one case, characterization of a liver lesion
detected at sonography in one case, loss of
weight in one case, acute abdominal pain
in two cases, and psoas abscess in one case.
The numbers of ERCP, CT, and MRI studies
reviewed for patients with annular pancreas
were 40, 22, and 13. The control group consisted of 19 men and 11 women (mean age,
49 years). The final diagnoses among these
patients were biliary dyskinesia in six cases, sphincter of Oddi dysfunction in 17 cases,
and no abnormality in seven cases.
Complete and Incomplete Annular Pancreas
The diagnostic pathway for the patients
with annular pancreas is shown in Figure 1.
MR or CT images were available in 24 cases.
In all cases, the annulus surrounded the second part of the duodenum, never the first or
third part. At macroscopic inspection, visible
pancreatic tissue or annular duct was seen to
encircle the duodenum to its lateral aspect in
15 of the 24 cases (63.5%) (Fig. 2). In the other nine cases (37.5%), the annulus did not surround the pancreas completely. In these cases,
the presence of annular pancreas was confirmed at ERCP (n = 6) or surgically (n= 3).

AJR:193, August 2009

Annular Pancreas in Adults

5) (Fig. 6) or associated pancreas divisum (n =
3). The two imaging techniques were judged
equally contributory in the other three cases.
In four cases, the CT scans had been read at
the referring institution as showing a pancreatic mass, but imaging at our institution confirmed the presence of annular pancreas.
Secretin-enhanced MRCP was compared
with non-secretin-enhanced MRCP in 13
cases. Secretin-enhanced MRCP was superior in showing the presence of the annular
duct (n = 2) and disease in the annular duct
(n = 3) (Fig. 7) and in showing the presence
of associated pancreas divisum (n = 2). Secretin-enhanced MRCP and conventional
MRCP were equivalent in showing the anatomic features in the other six cases.

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42 patients with annular pancreas

Complete annular pancreas (n = 33)

ERCP only (n = 18)

Incomplete annular pancreas

CT or MRI (n = 9)

CT, MRI, or both (n = 15)*

Surgical
proof (n = 3)

ERCP
proof (n = 6)

Fig. 1Chart shows diagnostic pathway for 42 patients. ERCP and surgical confirmation were reference
standards in cases of incomplete annular pancreas. Asterisk indicates that patients with complete annular
pancreas who underwent CT or MRI had additional confirmation of diagnosis at ERCP (n = 5) or surgery (n =
6). Other patients (n = 4) had no additional confirmation of diagnosis, but ring of enhancing pancreatic tissue
encircling duodenum was seen at CT or MRI.

These cases were considered radiologically

incomplete annular pancreas (Fig. 3). The
configuration of the pancreatic head surrounding the duodenum was circular in five cases of
incomplete annular pancreas. In the other
four cases, the configuration of the annulus
was triangular, producing a crocodile jaw appearance (Fig. 4). Three of the nine patients
with gastric outlet obstruction had incomplete annular pancreas. Thus the risk of duodenal obstruction due to incomplete annular
pancreas (33%) was similar to that of complete annular pancreas (40%, p = 0.75).
The morphologic features of the pancreatic head seen at CT or MRI in the 24 cases of
proven annular pancreas (study group) were
compared with those in the 30 cases of no
evidence of annular pancreas or pancreatitis
at ERCP (control group) (Fig. 5). The finding of pancreatic tissue extending in a posterolateral direction to the duodenum had a
sensitivity and specificity for annular pan-

creas of 92% and 100%. In comparison, the

presence of pancreatic tissue anterolateral to
the duodenum was significantly less specific (73%, p = 0.01, Mann-Whitney test) and
slightly but not significantly more sensitive
(96%, p = 0.52).

Pancreatic Ductal Anatomy and Disease

Ductal anatomy was assessed in 40 patients who underwent ERCP. Fifteen patients
(37.5%) had associated pancreas divisum.
Evidence of moderate or severe chronic
pancreatitis, according to criteria previously described [23], was found in 19 patients
(47.5%). The annular duct joined the main
duct in the head (n = 35) or the accessory
duct (duct of Santorini) (n = 5). In no case
did the annular duct join the common bile
duct or drain directly into the duodenum.
It was possible to compare CT and MR images in 11 cases. MRI (including MRCP) was
superior to CT in showing the annular duct (n =

Fig. 230-year-old woman with abdominal pain.

A, T2-weighted axial MR image (TR/TE, 5,301/104; flip angle, 150; echo train length, 13) shows annular duct
(arrowhead) surrounded by thin rim of pancreatic tissue with posterolateral extension to second part of
duodenum (straight arrow), findings consistent with complete annular pancreas. Annular duct appears to join
main duct (curved arrow).
B, ERCP image shows annular duct (arrowhead) curving to right of endoscope.

AJR:193, August 2009

Other Findings
Pancreatic cancer was found in two cases and intraductal papillary mucinous neoplasm in one case. In four cases, the finding
of a mass in the pancreatic head led to pancreatoduodenectomy. The surgical pathologic examination showed only inflammatory
fibrosis. Common bile duct dilatation was
seen in 15 patients, two of whom had malignant disease.
Discussion
The pancreas develops from a single dorsal and two ventral buds that first appear in
the fifth week of gestation as outgrowths of
the primitive foregut. The two ventral buds
rapidly fuse. By the seventh gestational
week, expansion of the duodenum causes the
ventral bud to rotate and pass behind the duodenum from right to left and fuse with the
dorsal bud. The ventral bud forms the inferior part of the uncinate process and the inferior head of the pancreas, and the dorsal bud
gives rise to the tail and the body. Fusion of
the ducts of the two buds produces the main
pancreatic duct. Annular pancreas results
from failure of the ventral bud to rotate with
the duodenum, resulting in envelopment of
the duodenum. Two theories have been proposed by Lecco [24] and Baldwin [25] to explain the embryologic mechanism of annular
pancreas and the ductal configuration. Neither theory explains all cases of annular pancreas, but it is clear that annular pancreas is
derived from the ventral bud of the pancreas [26]. It is estimated that between one half
and two thirds of cases of annular pancreas
in adults remain asymptomatic. When symptomatic, the presentation is usually in the
third to sixth decade with abdominal pain,

457

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Sandrasegaran et al.
Fig. 350-year-old woman with new onset of
symptoms of gastric outlet obstruction.
A, Axial CT image shows no pancreatic tissue around
duodenum (curved arrow). Distention of stomach
(straight arrow) is evident.
B, Axial CT image at slightly more inferior level in
relation to A shows head of pancreas (arrowhead)
extending in posterolateral direction to duodenum
(arrow) without encirclement. Presence of annular
pancreas was confirmed at duodenoduodenostomy.

Fig. 461-year-old man with vomiting and abdominal fullness.

A and B, Axial CT images , with A more superior to B, show duodenum (arrow) partially encircled by head of pancreas, which has crocodile jaw appearance (arrowheads).
Diagnosis was radiologically incomplete annular pancreas.
C, Photograph obtained during laparotomy shows annular band (arrowheads) circling distended duodenum (arrow).

Annular Pancreas

Normal Pancreas

22

Pancreas extending
in anterolateral
direction (10- to
12-oclock position)
to second part of
duodenum

Pancreas extending
in posterolateral
direction (6- to
8-oclock position)
to second part of
duodenum

CT or MRI Finding
Pancreas to left
of second part
of duodenum

Pancreas extending
around second part
of duodenum but not
completely

Configuration

Complete annulus
15

postprandial fullness, vomiting, upper gastrointestinal bleeding from peptic ulceration,

acute or chronic pancreatitis, or in rare instances, biliary obstruction [5, 27, 28].

458

Fig. 5Comparison of
findings in patients with
annular pancreas and
controls with normal
pancreas. Values are
numbers of patients.

Our series is the largest, to our knowledge,

collection of radiologic and ERCP findings on
annular pancreas, more than double the number of cases in all previous series combined

that were found in our literature search [5

21]. Our findings suggest that a complete ring
of pancreatic tissue around the duodenum is
not required for a diagnosis of annular pancreas. More than one third (37.5%) of patients
in this study had a radiologically incomplete
annulus on images but ERCP or surgical confirmation of annular pancreas. Patients such as
these most likely have a thin band of pancreatic tissue, not seen at CT or MRI, incorporated
in the duodenal wall [29, 30]. Nevertheless, an
imaging finding of pancreatic tissue extending in a posterolateral direction to the second
part of the duodenum in the appropriate clinical setting, such as unexplained chronic pancreatic or gastric outlet obstruction, should
raise the suspicion of annular pancreas. The
anterolateral extension of pancreatic tissue to
the second part of the duodenum is less specific for annular pancreas. We believe a crocodile jaw configuration of pancreatic tissue anterior and posterior to the duodenum is highly
suggestive of incomplete annular pancreas.
Our findings suggest that incomplete annular
pancreas is not a benign diagnosis and that
in adults it carries a risk of gastric outlet obstruction similar to that of complete annular
pancreas. The best noninvasive method of ascertaining the ductal configuration and the

AJR:193, August 2009

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Annular Pancreas in Adults

Fig. 640-year-old woman with abdominal pain and CT report of normal pancreas at referring institution.
A, CT image shows thin rim of pancreatic tissue (arrowheads) anterior to duodenum (arrow).
B, MRCP image (TR/TE, 2,000/755; flip angle, 180; echo-train length, 256) shows annular duct (solid arrow) joining duct of Santorini (arrowhead). Main pancreatic duct
(dashed arrow) does not have stricture. Duodenal lumen (winged arrow) is narrow.
C, ERCP image shows annular duct (solid arrow) joining duct of Santorini (arrowhead) and normal main duct (dashed arrow). Annular duct extends to right of duodenum
(indicated by endoscope tip) and main pancreatic duct.

Fig. 746-year-old woman with chronic pancreatitis.

A, Pre-secretin MRCP image shows annular duct (arrowhead). Apparent filling defect at common hepatic duct
(arrow) is caused by crossing vessel.
B, MRCP image obtained 7 minutes after injection of secretin shows irregularity of annular duct with side
branch dilatation (arrowhead). Chronic pancreatitis is predominantly confined to annulus, with main duct
(straight arrow) exhibiting normal caliber without structure or side branch disease. Although it can be
appreciated before secretin injection, pancreas divisum is better visualized on secretin-enhanced images. Use
of secretin also allows functional assessment of pancreatic exocrine reserve. At expected peak of action [22],
exocrine output fills only duodenal bulb (curved arrow), indicating suboptimal response.

presence of disease in annular pancreas appears to be secretin-enhanced MRCP.

The association between annular pancreas
and other pathologic conditions of the pancreas in this cohort was impressive. Pancreas
divisum and chronic pancreatitis were present in 37% and 48% of patients. These figures are substantially higher than the 23.5%
[31, 32] and 0.54% [33, 34] prevalence of
pancreas divisum and chronic pancreatitis
in the general population. This finding may
have occurred because, to identify subjects,
we used the ERCP database, which has a bias
toward inclusion of cases of pancreatic disease. A previous study [35] showed that common bile duct dilation is not a significant risk
factor for the presence of malignancy. In our

AJR:193, August 2009

study, the risk of pancreatic malignancy was

high (two of 15 cases, 13%) when the patient
had common bile duct obstruction. However,
biliary dilation also may be related to the severity of chronic pancreatitis or ductal compression by the annulus.
The limitations of this study were the retrospective nature and the aforementioned selection bias. In addition, examinations with
false-negative findings were not included,
and it is not possible to estimate the true incidence of annular pancreas. It would be almost impossible to undertake a prospective
study of annular pancreas because of its relative rarity. The reviewers were not blinded
to whether the diagnosis was annular pancreas. This factor may have led to bias in de-

termining the sensitivity and specificity of

CT features for incomplete annular pancreas. We used ERCP and surgery as the reference standards for determining the presence
of annular pancreas in cases of radiologically incomplete annular pancreas. Although
ERCP is a well-accepted reference standard
for pancreatic ductal disease, we are aware
of cases in which obstruction of the annular
duct close to its origin resulted in false-negative ERCP findings. The small number of
patients who underwent ERCP and the other
imaging studies makes the results of detailed
statistical analysis specious.
We conclude that a complete ring of pancreatic tissue around the duodenum is not required for the radiologic diagnosis of annular
pancreas; incomplete annulus was found in
more than one third of patients in this study.
Secretin-enhanced MRCP may be the best
noninvasive method of assessing ductal anatomy and should be considered when the diagnosis of annular pancreas is entertained.
The imaging finding of pancreatic tissue
with posterolateral extension to the duodenum in a patient with suspected chronic pancreatitis or gastric outlet obstruction or the
finding of a crocodile jaw appearance of the
pancreatic head should raise concern about
the presence of annular pancreas.
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