Kelsey Collins, MD1, Joseph Constantino, MD1, Philip Chuang, MD2, Ray Dong, MD3, Violetta Laskova, MD4, Evin McCabe, MD3
1Mount Sinai Beth Israel Medical Center / Icahn School of Medicine at Mount Sinai, New York, NY; 2Mount Sinai Beth Israel, Mount Sinai St. Luke's, Mount Sinai West, New York, NY; 3Mount Sinai Beth Israel Medical Center, New York, NY; 4MSHS, New York, NY
Introduction: Annular pancreas, a congenital anomaly caused by a complete or partial ring of pancreatic tissue surrounding the descending duodenum, is uncommon and often presents in childhood with gastric outlet obstruction. Although the incidence is 5-15 per 100,000 patients based on autopsy, the true incidence rate is unknown as many patients are asymptomatic. We present a case of recurrent abdominal pain and associated uncontrolled Diabetes and undiagnosed annular pancreas.
Case Description/Methods: An 83-year-old female with a history of CAD, DM2, HTN, HLD, GERD, and recurrent abdominal pain with labile diabetes presented to the ED with abdominal pain for 2 days. The pain was epigastric and associated with constipation and inability to pass flatus for 1 day. Labs were significant for glucose of 529, ALP of 204, AST of 96, ALT of 108, lactate of 2.6, and HbA1c of 16.6. She underwent CT Abdomen/Pelvis, which showed marked dilatation of the 1st two portions of the duodenum with an abrupt transition point and distended colon with fecal material without evidence of obstruction. An upper GI series was obtained; which was remarkable for obstruction at the 2nd portion of the duodenum. NGT decompression of barium from the stomach was performed and endoscopy showed extrinsic compression between the 1 st and 2 nd portions of the duodenum. EUS was subsequently performed but could not confirm the stenosis; sonography was suspicious for annular pancreas. MRCP was performed showing glandular parenchymal atrophy of the pancreatic body and tail and partial annular pancreas causing obstruction of the 2 nd portion of the duodenum. Over the next few days her insulin regimen was titrated and her symptoms improved with subsequent discharge. On follow-up she and her family ultimately declined surgical or duodenal stent placement due to the patient’s multiple comorbidities.
Discussion: Although most asymptomatic annular pancreas never cause problems, they can still become symptomatic. The patient’s annular pancreas likely resulted in partial obstruction which contributed to recurrent misdiagnosed pancreatitis. This resulted in impairment of her pancreatic function, worsening her DM thus potentiating her labile diabetes. Additionally, years of fibrosis and scarring from inflammation of her annular pancreas likely lead to her eventual duodenal narrowing, further exacerbating symptoms.
Citation: Kelsey Collins, MD; Joseph Constantino, MD; Philip Chuang, MD; Ray Dong, MD; Violetta Laskova, MD; Evin McCabe, MD. P0954 - RECURRENT ABDOMINAL PAIN IN THE ELDERLY: AN INTERESTING CASE OF SBO AND BRITTLE DIABETES DUE TO UNDIAGNOSED ANNULAR PANCREAS. Program No. P0954. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.