CASE REPORT: ABDOMINAL IMAGING
Annular Pancreas
Emphasis on Magnetic Resonance Cholangiopancreatography Findings
Jin-Young Choi, MD,* Myeong-Jin Kim, MD,† Joo Hee Kim, MD,* Joon Seok Lim, MD,*
Young Taik Oh, MD,* Jae-Joon Chung, MD,* Si Young Song, MD,‡ Jae Bock Chung, MD,‡
Hyung Sik Yoo, MD,* Jong Tae Lee, MD,* and Ki Whang Kim, MD*
Abstract: An annular pancreas is a rare congenital anomaly in
which a portion of the pancreatic tissue surrounds the duodenum.
Magnetic resonance cholangiopancreatography (MRCP) is used ex-
tensively for evaluating the pancreatobiliary ducts. There have been
only few cases in which MRCP clearly demonstrated the types of
annular ducts, however. Two cases of an annular pancreas based on a
new classification of the morphologic type are reported.
Key Words: annular pancreas, magnetic resonance cholangiopan-
creatography, pancreatic duct
(J Comput Assist Tomogr 2004;28:528–532)
A n annular pancreas is a rare congenital anomaly in which a
ring of pancreatic tissue surrounds the duodenum.1 Al-
though the exact cause is unknown, several theories have been
proposed. Lecco2 suggested that the tip of the right ventral bud
adheres to the duodenal wall and stretches to form a ring during
normal rotation. Baldwin3 reported that the left ventral bud
persists, which develops to complete a circle of pancreatic tis-
sue around the duodenum. Each theory has some limitations,
however, and accounts for only a few types of annular pan-
creata.1–5 Recently, a new embryologic hypothesis of an annu-
lar pancreas that can account for the developmental mecha-
nism of the arrangement of annular ducts was reported.6 There
have been reports that have described the characteristic imag-
ing features of an annular pancreas that are useful for diagnos-
ing this entity.7–11 To the best of the current authors’ knowl-
edge, however, the imaging features have not been correlated
with the morphologic types of annular pancreata based on the
different embryologic theories. We report 2 cases of an adult
From the *Department of Diagnostic Radiology, Yonsei University College of
Medicine, Seoul, Korea, †Brain Korea 21 Project for Medical Science,
Yonsei University College of Medicine, Seoul, Korea, and ‡Division of
Gastroenterology, Department of Internal Medicine, Yonsei University
College of Medicine, Seoul, Korea.
Reprints: Dr. Myeong-Jin Kim, Brain Korea 21 Project for Medical Science,
Yonsei University College of Medicine, Seodaemun-ku Shinchon-dong
134, Seoul 120-752, Korea. (e-mail: kimnex@yumc.yonsei.ac.kr).
Copyright © 2004 by Lippincott Williams & Wilkins
528 J Comput Assist Tomogr • Volume 28, Number 4, July/August 2004
annular pancreas in which the findings on magnetic resonance
cholangiopancreatography (MRCP) images reflect the new
embryologic hypothesis.
CASE REPORTS
Case 1
A 39-year-old man with a history of diabetes mellitus
presented for evaluation of elevated CA19-9 (55 U/mL; nor-
mal <37 U/mL). He had no clinical symptoms. A computed
tomography (CT) scan revealed pancreatic tissue extending
from the pancreatic body and completely encircling the duo-
denum. A magnetic resonance (MR) examination, including
MRCP, was performed with a 1.5-T system (Horizon; General
Electric Medical Systems, Milwaukee, WI) using a phased-
array multicoil. The MR imaging parameters were as follows:
1) a breath-hold, T1-weighted, fast, multiplanar, spoiled gra-
dient–recalled echo in-phase sequence (140/4.2); 2) an out-of-
phase sequence (120/1.6) with a flip angle of 90°, 1 signal ac-
quired, a matrix of 256 × 192, an 8-mm section thickness, a
zero gap, and interleaved; 3) a breath-hold, T2-weighted,
single-shot, half-Fourier sequence with an effective echo time
of 189 milliseconds, a matrix of 256 × 192, and a 5-mm section
thickness with a 1-mm gap; and 4) MRCP images using a se-
quential multiple thin-section technique (single-shot, half-
Fourier, rapid acquisition and relaxation sequence with an ef-
fective echo time of 66–100 milliseconds; field of view of 32
cm × 24 cm; section thickness of 4 mm with no gap; receiver
bandwidth of 31.3 kHz; matrix size of 256 × 256; and half-
Fourier acquisition), followed by a maximum intensity projec-
tion and single thick-slab technique (echo time of 1005 milli-
seconds; section thickness of 30 mm; and field of view of 24
cm × 24 cm in the coronal, lateral, and left and right 15°, 30°,
and 45° oblique planes). The transverse axial T1-weighted MR
images showed that the duodenal second portion was sur-
rounded by pancreatic tissue (Fig. 1A). The MRCP images
showed an aberrant pancreatic duct encircling the descending
portion of the duodenum (see Fig. 1B). The aberrant pancreatic
duct, the common bile duct, and the Wirsung duct were joined
together and opened to the duodenum. Endoscopic retrograde
J Comput Assist Tomogr • Volume 28, Number 4, July/August 2004 Annular Pancreas

FIGURE 1. A, Transverse axial T1-weighted magnetic resonance images show the duodenal second portion surrounded by
pancreatic tissue (white arrow). B, Magnetic resonance cholangiopancreatography shows an aberrant pancreatic duct (white
arrow) encircling the descending portion of the duodenum. The aberrant pancreatic duct (white arrow), common bile duct, and
Wirsung duct (arrowheads) join together and open to the duodenum. C, ERCP shows an aberrant pancreatic duct (black arrows)
encircling the duodenum.

cholangiopancreatography (ERCP) confirmed the annular
pancreas, showing an aberrant pancreatic duct that encircled
the duodenal second portion and joined the common bile duct
and Wirsung duct (see Fig. 1C). The common bile duct and
pancreatic duct were not dilated.
Case 2
A 51-year-old man was admitted as a result of recent
onset of jaundice. A laboratory evaluation showed elevated to-
tal bilirubin (8.6 mg/dL) and alkaline phosphatase (500 IU/L)
levels. A CT scan and ultrasonography showed enlargement of
the pancreatic head and pancreatic tissue surrounding the sec-
ond portion of the duodenum (Fig. 2A).
Magnetic resonance cholangiopancreatography was
performed employing the same parameters used in the first
case. The right anterior oblique projection showed an annular
pancreatic duct that surrounded the second portion of the du-
odenum and joined the Wirsung duct (see Fig. 2B). ERCP re-
vealed an annular pancreatic duct that surrounded the second
portion of the duodenum and joined with the Wirsung duct,
which is consistent with the MRCP findings (see Fig. 2C). The
common bile duct could not be visualized because of unsuc-
cessful cannulation of its orifice as a result of the duodenal
stenosis. A diagnosis of annular pancreas was made based on
these findings.
DISCUSSION
An annular pancreas is a rare (1 in 20,000 cases) congen-
ital anomaly in which the head of the pancreas totally or par-
tially surrounds the duodenum.1 Some patients with this
anomaly develop a duodenal stenosis, obstructive jaundice,
and pancreatitis; however, many remain asymptomatic, and
the anomaly is only discovered incidentally in adulthood.1,4
Although several theories for the origins of an annular
pancreas have been proposed, the pathogenesis is still contro-
versial. Two important concepts concerning development of
the annular pancreas from the ventral anlage have been pro-
posed.1–4 Lecco2 suggested that the tip of the right ventral bud
adheres to the duodenal wall and stretches to form a ring during
normal rotation. Baldwin3 reported that the left ventral bud
persists and develops to encircle the duodenum completely
with pancreatic tissue. The difference between Lecco’s and
Baldwin’s hypotheses is that the ventral pancreatic anlage is
single in the former and paired in the latter.6,12 Many gastro-
enterologists and pathologists believe that the ventral pancre-

© 2004 Lippincott Williams & Wilkins 529

Choi et al J Comput Assist Tomogr • Volume 28, Number 4, July/August 2004

FIGURE 2. A, Computed tomography multiplanar reconstruction image demonstrates the annular pancreas encircling the duo-
denum (white arrows), resulting in obstruction. B, Magnetic resonance cholangiopancreatography shows an annular pancreatic
duct (white arrow) surrounding the duodenum. The annular duct opens to the Wirsung duct (white arrowheads). The relation
between the biliary tree and the pancreatic duct can be properly evaluated. C, ERCP demonstrates the annular pancreatic duct
(black arrow) surrounding the duodenal second portion and joining with the Wirsung duct (white arrowheads). The common bile
duct could not be visualized because of the unsuccessful cannulation of its orifice as a result of the duodenal stenosis. Therefore,
the relation between the biliary tree and the pancreatic duct could not be adequately evaluated.

atic anlage is initially paired, with the left lobe subsequently
disappearing during development as described by Odger.13
The histogenesis of the ventral pancreatic anlage is also con-
troversial, however, because most of the resected and autop-
sied annular pancreata that have been investigated histopatho-
logically support Lecco’s hypothesis.14,15 Moreover, Bald-
win’s explanation necessitates the subsequent fusion of the
ducts to explain the anatomy. Therefore, Baldwin’s explana-
tion is regarded as less suitable than Lecco’s theory. Histopath-
ologic analyses of an annular pancreas support Lecco’s hy-
pothesis, whereas some clinicopathologic analyses of pan-
creata with pancreaticobiliary maljunction support Baldwin’s
hypothesis of paired ventral pancreata.6,12
Recently, a new embryologic hypothesis of an annular
pancreas to account for the mechanism of the annular pancreas
was reported. Kamisawa et al6 suggested that the tip of the left
ventral anlage initially adheres to the duodenum and stretches
to form a ring during development. According to their theory,
several arrangements of the annular ducts can be created de-
pending on whether the tip is proximal or distal to the bile duct
(Fig. 3). This is a modification of Baldwin’s theory in that the
persistence of the left ventral anlage leads to an annular pan-
creas and the location of the tip of the left ventral anlage creates
the arrangements of the annular ducts. In addition, recent his-
topathologic and immunohistochemistry investigations by No-
bukawa et al12 are consistent with Baldwin’s hypothesis.
These investigators described a case of an annular pancreas in
which a ring originating from the left lobe of the paired ventral
pancreata formed around the duodenum.
Several anatomic classifications have been proposed in
the literature. The simplest classification is that provided by
Lin,16 who identified 3 main types of annular pancreata ac-
cording to the fusion pattern of the ventral and dorsal pancre-
atic ducts. Johnston17 classified annular pancreata into an ex-
tramural type and an intramural type in line with the clinical
presentation and the surgical viewpoint. Yoshioka18 classified
the annular duct into 4 types by taking into consideration the
anatomic situation and the place of drainage of the annular duct
(Fig. 4). The annular duct opens into the Wirsung duct (type 1),
into common bile duct without communication with the Wir-
sung duct (type 2), into the major duodenal papilla with an
absence of the Wirsung duct (type 3), and into the Santorini
duct (type 4). Most cases are classified as type 1. Type 4 is
derived from the dorsal anlage. Yoshioka’s classification of
annular pancreata emphasizes the need to consider the ana-
tomic situation and the place of drainage of the annular duct.18

530 © 2004 Lippincott Williams & Wilkins

J Comput Assist Tomogr • Volume 28, Number 4, July/August 2004 Annular Pancreas

FIGURE 3. Illustrations of new hypothesis of annular pancreas development show the duct arrangement. Yoshioka’s type 1 (A),
type 2 (B), and type 3 (C) are shown. VP, ventral pancreas; DP, dorsal pancreas; BD, bile duct; LV, left ventral bud; RV, right ventral
bud; DU, duodenum.

This can explain the embryologic mechanism of the annular
ductal arrangement.
The imaging features of an annular pancreas are well
known.7–11 An annular pancreas can be diagnosed by visual-
izing not only the pancreatic duct but the pancreatic paren-
chyma surrounding the duodenum on either CT or MR imag-
ing. Contrast-enhanced abdominal CT can demonstrate com-
plete or partial annular pancreatic tissue around the duodenum.
The fat-saturated T1-weighted MR images are useful to define
clearly the high signal intensity of the pancreatic tissue encir-
cling the duodenum. ERCP is particularly specific in diagnos-
ing an annular pancreas. The ERCP findings include an aber-
rant pancreatic duct that encircles the duodenum and usually
connects with the main pancreatic duct or the common bile
duct near the ampulla of Vater. It enters the duodenum in a
small numbers of cases, however.9,10 Magnetic resonance
cholangiopancreatography allows the classification of annular
pancreata according to the different duct types. It can assess
the association with a pancreas divisum and might exclude a
rare malignancy associated with this anomaly.11,19–23 Mag-
netic resonance cholangiopancreatography is also a noninva-
sive method for visualizing the pancreaticobiliary duct without
the need to inject contrast medium and is not operator depen-
dent.10,11,21–23

FIGURE 4. Illustrations show the classification of the annular duct by Yoshioka. CBD, common bile duct; WD, Wirsung duct; SD,
Santorini duct; AD, annular duct.

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Choi et al J Comput Assist Tomogr • Volume 28, Number 4, July/August 2004
As stated previously, several embryologic hypotheses
have limitations in explaining the ductal anatomy of an annular
pancreas. Lecco’s hypothesis is a less suitable explanation for
Yoshioka type 2 cases (case 1 in this report), because the an-
nular duct originating from the right ventral bud must join with
the Wirsung duct. Baldwin’s hypothesis is also unsatisfactory
in explaining the latter case (Yoshioka type 1), because fusion
of the ducts from the left ventral bud and right ventral bud is
required. The new embryologic hypothesis, which is basically
Baldwin’s hypothesis, sufficiently describes both of our cases
as shown in the illustrations. In our first case, the tip of the left
ventral bud was located distal to the bile duct and the annular
duct from the left ventral bud joined with the common bile
duct. In our second case, the tip of the left ventral bud proximal
to the bile duct adhered to the duodenum and the annular duct
originating from the left ventral bud opened to the Wirsung
duct.
In the 2 cases presented in this report, the shape and fea-
tures of the pancreatic duct in the annular portion were clearly
visualized by MRCP images. In addition, the relation between
the biliary tree and the pancreatic duct, which was difficult to
image by ERCP, was properly evaluated. These cases suggest
that MRCP can identify the different morphologic types based
on the new causative classification of this rare anomaly.
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© 2004 Lippincott Williams & Wilkins