72 J Gandhara Med Dent Sci July - September 2025
CASE REPORT
:
:
ANNULAR PANCREAS AS A CAUSE OF NEONATAL DUODENAL OBSTRUCTION: A CASE
REPORT
Karishma Siraj1, Saqib Zaman2, Lyaba Atta3, Fatima Shafiq4, Haseena Ali5, Mohammad Waqar6
ABSTRACT
The annular pancreas is a rare congenital anomaly that encircles a portion of
the duodenum, causing duodenal obstruction with a wide range of clinical
presentations. In neonates, it is one of the primary causes of duodenal
obstruction, presenting as frequent vomiting, dehydration, abdominal
distention, and tenderness. In adults, it can present as pancreatitis, duodenal
or gastric outlet obstruction, or stenosis. This condition should be recognized
early, as early intervention yields better outcomes. We present a case of a 6-
day-old neonate with duodenal obstruction caused by the annular pancreas—
the neonate presented with persistent vomiting and abdominal distention with
severe dehydration and electrolyte derangements. X-ray of the abdomen
showed a classic double bubble sign indicative of duodenal obstruction. The
infant underwent resuscitation with intravenous fluids, analgesics, and a
surgical laparotomy. Where the bowel was decompressed and
duodenodenostomy was performed. Postoperatively, the patient's recovery
was uneventful, and he was discharged home. Feeding was gradually
introduced with no complications. The rarity of this condition, its
presentation, and its successful management have prompted us to present the
case.
KEYWORDS: Annular Pancreas, Duodenal Obstruction, Neonate,
Pancreatic Congenital Anomaly
How to cite this article
Siraj K, Zaman S, Atta L, Shafiq F,
Ali H, Waqar M. Annular Pancreas as
A Cause of Neonatal Duodenal
Obstruction: A Case Report. J
Gandhara Med Dent Sci. 2025;12(3):
72-74. https://doi.org/10.37762/jgmds.
Date of Submission: 18-04-2025
Date Revised: 06-05-2025
Date Acceptance: 03-06-2025
2Post graduate Trainee, Department of
Pediatrics, Lady Reading Hospital,
Peshawar
3Post graduate Resident, Department of
Pediatrics, Lady Reading Hospital,
Peshawar
4Post graduate Resident, Department of
Pediatrics, Lady Reading Hospital,
Peshawar
5Post graduate Resident, Department of
Pediatrics,
6Post graduate Resident, Department of
Pediatrics, Lady Reading Hospital,
Peshawar
Correspondence
1Karishma Siraj, Post graduate
Resident, Department of Lady Reading
Hospital, Peshawar
+92-341-911016
sirajmuhammadsdo@gmail.com
INTRODUCTION
The term "annular pancreas" refers to a thin rim of
pancreatic tissue encircling a portion of the duodenum,
typically the second portion, resulting in distal bowel
obstruction .1,2 With an incidence of 1 in 20,000 live
births, it is one of the rarest congenital anomalies,
classified into six types. Type 1 is the most prevalent, in
which the annular duct flows directly into the main
pancreatic duct. Type 2 encircles the Wirsung's duct
and drains into the major duodenal papilla. The other
four types are rare.3 The annular pancreas is one of the
primary causes of partial or complete duodenal
obstruction.4 It is also associated with other conditions,
such as cardiac defects, duodenal atresia, and intestinal
malrotation.5 The annular pancreas exhibits symptoms
based on the severity of compression it applies to the
duodenum, varying from asymptomatic cases
throughout life to complete bowel obstruction, even in
the early neonatal period.6 Due to the rarity of this
condition, we are prompted to report a case of annular
pancreas with duodenal atresia and obstruction in a
neonate.
CASE PRESENTATION
We report a 6-day-old male neonate who presented to
the emergency department at Lady Reading Hospital,
Peshawar, with frequent episodes of bilious vomiting
and decreased oral intake. He was born full term, with a
birth weight of 2.5 kg, through a normal vaginal
delivery at the hospital, along with normal height and
head circumference fontanelles. He had a normal Apgar
score at birth. Both his parents are in their late twenties
and are in good health. There was no significant
antenatal history of TORCH infections or exposure to
teratogens. Additionally, his mother had no comorbid
conditions, such as gestational diabetes and
hypertension, indicating an uncomplicated full-term
pregnancy. Upon examination, the neonate appeared
unwell, lethargic, drowsy, dehydrated, and febrile, with
weak Moro and suck reflexes. The abdominal
12-3.719
73J Gandhara Med Dent Sci
July - September 2025
Obstruction was relieved, and a duodenostomy was
performed. Postoperatively, the patient was kept nil per
mouth, and intravenous fluids, analgesics, and
antibiotics were administered. Recovery progressed
without complications, and the patient was monitored in
the ward for proper management.
DISCUSSION
The annular pancreas is a rare congenital anomaly in
which ectopic pancreatic parenchymal tissue encircles
the duodenum, potentially leading to duodenal
obstruction.1,2 Its pathogenesis involves certain genetic
factors, which are supported by the association with
microduplication on chromosome 6q24. The annular
pancreas is often associated with other congenital
anomalies of the gastrointestinal system, including
malrotation of the intestine, atresia, imperforate anus,
tracheoesophageal fistula, and cardiac
abnormalities.1,2 Annular pancreas on antennal scan
usually presents with polyhydramnios due to duodenal
obstruction. Shortly after birth, a neonate with an
annular pancreas usually presents with bilious
vomiting, abdominal distention, and delayed passage of
meconium .2,6 Jaundice results from obstruction of the
intrapancreatic portion of the common bile duct due to
edema of the pancreatic head.7 In adults, the majority of
cases remain asymptomatic until the third to sixth
decade of life and then present with various
complications like peptic ulcer, duodenal obstruction,
pancreatitis, and obstructive jaundice.8 The initial
diagnosis can be made by a plain X-ray, which shows
the classic double bubble sign.9 CT scan or MRI studies
show enlargement of the pancreatic head with
enhancement of the 2nd portion of the duodenum.10
MRI is best compared to a CT scan due to the high
signal intensity of T1 fat-suppressed imaging. ERCP is
the gold standard for preoperative diagnosis of annular
pancreas.11 Despite radiological studies, surgical
confirmation is needed in 40% of cases and is the gold
standard method for confirmatory diagnosis, with the
added advantage of surgical correction.6 Treatment
depends upon clinical presentation and varies from case
to case. Generally, it includes symptomatic treatment
for acute pancreatitis and surgical interventions, such as
bypass techniques. Doudenoduodenostomy is the most
successful surgical treatment, followed by the division
of a portion of the annular pancreas and either
gastrojejunostomy or duodenojejunoostomy with a
Roux-en-Y loop. Pancreatic resection is reserved for
cases with a high suspicion of pancreatic
malignancy.6,12
examination revealed a distended abdomen with no
visceromegaly. Bowel sounds upon auscultation were
high-pitched and audible. The anus was normally
positioned and patent. The genitourinary examination
revealed that both testes were normally located in the
scrotum and had normal male genital and urethral
anatomy. The chest examination showed no signs of
distress, with normal vesicular breathing noted
bilaterally on auscultation. He had normal heart sounds
with no murmur. The neurological examination
revealed weak Moro and grasp reflexes, along with
normal muscle tone. A plain radiograph of the abdomen
was advised, which showed the classic double bubble
sign indicative of duodenal obstruction, as illustrated in
Figure 1.
Figure 1: Plain Radiograph Shows Classic Double Bubble Sign
(White Arrow) Suggestive of Duodenal Obstruction
Baseline investigations revealed deranged serum
electrolytes, including hyponatremia and hypokalemia.
Urea, creatinine, PT, and aPTT levels were slightly
abnormal. The remaining baseline investigations were
within normal ranges. The patient received resuscitation
with intravenous fluids and supportive treatment. A
surgical consultation was requested. Laparotomy was
performed on an emergency basis due to acute intestinal
obstruction. Preoperatively, it was observed that a
portion of the pancreas encircling the duodenum was
grossly dilated, and part of the duodenum was also
atretic, as shown in Figure 2.
Figure 2: Per-Operative Image Showing Ectopic Pancreatic
Tissue (White Arrow) Encircling Duodenum
CONCLUSIONS
In conclusion, Annular pancreas, despite its rarity, is an
Annular Pancreas as a Cause of Neonatal Duodenal
74 J Gandhara Med Dent Sci
July - September 2025
important cause of duodenal obstruction in neonates.
Early diagnosis through clinical evaluation and
imaging, followed by immediate resuscitation and
surgical management with correction, remains key for a
better prognosis in neonates. Clinicians should include
this condition in the differential diagnosis when
neonates present with signs and symptoms of intestinal
obstruction. Further research and reporting of similar
cases are recommended, as they may provide valuable
knowledge regarding the management of this rare
condition.
CONFLICT OF INTEREST: None
FUNDING SOURCES: None
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Annular Pancreas as a Cause of Neonatal Duodenal
Karishma Siraj - Concept & Design; Data Acquisition;
Drafting Manuscript; Critical Revision; Supervision; Final
Approval
Saqib Zaman - Concept & Design; Data Acquisition; Drafting
Manuscript; Critical Revision; Final Approval
Lyaba Atta - Concept & Design; Data Acquisition; Drafting
Manuscript; Critical Revision; Final Approval
Fatima Shafiq - Concept & Design; Data Acquisition ;Drafting
Manuscript; Critical Revision; Final Approval
Haseena Ali - Concept & Design; Data Acquisition; Drafting
Manuscript; Critical Revision; Final Approval
Mohammad Waqar - Concept & Design; Data Acquisition;
Drafting Manuscript; Critical Revision; Final Approval
AUTHORS CONTRIBUTION
The authors accept responsibility for all aspects of the work
and will ensure that any concerns regarding the accuracy or
integrity of any part are properly investigated and resolved.