Groove pancreatitis: a diagnostic challenge

Abstract

Groove pancreatitis is a distinct form of chronic pancreatitis characterized by inflammation and fibrous tissue formation, affecting the groove area between the head of the pancreas, the duodenum and the common bile duct. It is manifested on imaging by a sheet-like mass in the groove area near the minor papilla. Thickening of the duodenal wall and cystic transformation in the duodenal wall also represent common imaging features. Pathogenesis is still unclear, and clinical presentation is not specific. Endoscopic ultrasonography (EUS), computed tomography (CT) and magnetic resonance imaging (MRI) demonstrate imaging findings consistent with the disease in typical cases, but specific diagnosis is challenging in a number of patients where biopsy is required. The disease may mimic pancreatic, common bile duct or duodenal wall cancer that requires prompt and excessive surgical intervention, as opposed to groove pancreatitis where initial conservative treatment is suggested. The clinical, histopathological and radiological features on cross-sectional imaging of this entity are discussed in this review, and differential diagnostic clues are given.

Pancreatoduodenal Junction: Review of Anatomy and Pathologic Conditions

“…Although endoscopic biopsy of the duodenum ulcers are required, the findings on CT make pancreatic adenocarcinoma the more likely diagnosis pancreatic carcinoma is expected to invade along large peripancreatic vessels. 16 As reported by Yu et al on MR cholangiopancreatography, the stenosed intrapancreatic portion of the bile duct in patients with segmental form of groove pancreatitis used to be longer and smoother, in contrast to the abrupt and irregular ductal stenosis seen in patients with pancreatic carcinoma. 1 To consider groove pancreatitis in the differential diagnosis of pancreatic carcinoma is fundamental for an appropriate management.…”

“…Patients affected by GP are relatively young men with a history of alcohol abuse in the majority of cases. 16 The clinical setting is similar to other chronic pancreatitis, but recurrent vomiting due to progressive duodenal stenosis represents its main clinical feature. 17 The pathogenesis of groove pancreatitis remains controversial.…”

CT features of groove pancreatitis subtypes

“…An important differentiating feature is the normal appearance of the peripancreatic vessels in groove pancreatitis, which may be slightly displaced by the mass, but never show signs of obstruction or encasement. In contrast pancreatic carcinoma extending to the peripancreatic tissue or the duodenum is expected to invade and obstruct the peripancreatic vessels (12). MRCP may also be useful for differentiating segmental groove pancreatitis from pancreatic head carcinoma, as the intrapancreatic portion of the common bile duct in patients with groove pancreatitis has a long, smooth, narrowed configuration, while in patienys with pancreatic head carcinoma a circumscribed, irregular ductal stenosis or complete ductal obstruction tends to be seen (9).…”

“…MR can be useful for differentiating pure groove pancreatitis from acute pancreatitis with phlegmon in the groove, since the phlegmon in the groove always shows bright signal intensity on T2-weighted images (11). MRCP is useful for differentiating pure groove pancreatitis from distal cholangiocarcinoma, as in groove pancreatitis often a smooth long stricture of the distal intrapancreatic portion of the bile duct is seen, as opposed to an irregular and abrupt stricture in distal cholangiocarcinoma (12).…”

Pancreaticoduodenectomy and Outcomes for Groove Pancreatitis

“…The primary obstructive causes may include anatomical abnormalities such as heterotropic pancreatic tissue in the duodenum or functional variations, making these patients more susceptible to environmental pathogens from smoking and use of alcohol; in conjunction, an increase in the protein concentration and viscosity of the pancreatic juice, led to inflammation and subsequent calcification of the pancreas [11, 12]. Secondary causes include a history of gastrectomy causing trauma to the pancreatic head, duodenal ulcers, biliary tract disease, pseudocysts, and neoplasms [3, 13-17]. The Santorini duct may also be obstructed by protein plugs from true pancreatic cysts with intraluminal necrosis [16].…”