From the Guidelines
The management of annular pancreas focuses on treating symptoms and complications rather than the anatomical abnormality itself, with surgical bypass procedures being the mainstay of treatment for symptomatic patients. For patients with annular pancreas, the primary goal is to alleviate symptoms and prevent complications, rather than correcting the anatomical abnormality. The treatment approach involves a multidisciplinary team, including surgeons, gastroenterologists, and nutritionists.
- Key considerations in the management of annular pancreas include:
- Surgical bypass procedures, such as duodenojejunostomy or duodenoduodenostomy, to relieve duodenal obstruction while preserving pancreatic tissue 1
- Preoperative management with nasogastric decompression, fluid and electrolyte correction, and nutritional support
- Standard pancreatitis management for patients with associated pancreatitis, including bowel rest, pain control, and IV fluids
- Endoscopic interventions, such as ERCP with stent placement, for select cases with pancreatic duct obstruction
- Monitoring of asymptomatic annular pancreas discovered incidentally, with periodic follow-up to detect potential late complications
- Nutrition therapy plays a crucial role in the management of annular pancreas, with a focus on reducing steatorrhea and ensuring adequate energy intake 1.
- A diet rich in carbohydrates and protein, with a protein intake of 1.0-1.5 g/kg, is recommended
- Medium chain triglycerides (MCT) may be administered if adequate weight gain cannot be achieved and steatorrhea is persistent
- Fat-soluble vitamins and other micronutrients should be supplemented if clinical deficit is apparent
- Enteral nutrition (EN) may be indicated in patients who cannot ingest sufficient calories, with a peptide or amino acid-based formula recommended for overnight delivery via a jejunal tube 1.
- Parenteral nutrition (PN) is only indicated when EN is not possible, such as in severe stenosis of the duodenum prior to surgery.
From the Research
Management and Treatment Approach
The management and treatment approach for a patient with annular pancreas is individualized and depends on the presence and severity of symptoms.
- For asymptomatic patients, no treatment is required, as the condition may remain asymptomatic well into adulthood and be incidentally detected on abdominal imaging done for other indications 2.
- For symptomatic patients, the treatment approach varies depending on the symptoms and complications present.
Medical Therapy
- Medical therapy may be sufficient for patients with mild symptoms, such as abdominal pain, and can be used as a first-line treatment 3.
Surgical Intervention
- Surgical intervention is often required for patients with duodenal obstruction, duodenal ulcer, or other complications that cannot be managed conservatively 3, 4, 5.
- Various surgical procedures can be used, including duodeno-jejunal bypass, Billroth II gastrectomy, choledochojejunostomy, endoscopic sphincterotomy, or biliary stenting, and pancreatic resection 4, 5.
Treatment of Acute Pancreatitis
- Acute pancreatitis associated with annular pancreas can often be managed conservatively, without the need for surgical intervention, unless there are competing indications for intervention 2.