Characteristic clinical and pathologic features for preoperative diagnosed groove pancreatitis.

Abstract

Groove pancreatitis is a rare specific form of chronic pancreatitis that extends into the anatomical area between the pancreatic head, the duodenum, and the common bile duct, which are referred to as the groove areas. We present the diagnostic modalities, pathological features and clinical outcomes of a series of symptomatic patients with groove pancreatitis who underwent pancreaticoduodenectomy.
Six patients undergoing pancreaticoduodenectomy between May 2006 and May 2009 due to a clinical diagnosis of symptomatic groove pancreatitis were retrospectively included in the study.
Five cases were male and one case was female, with a median age at diagnosis of 50 years. Their chief complaints were abdominal pain and vomiting. Abdominal computed tomography, endoscopic ultrasound and endoscopic retrograde cholangiopancreatography were performed. Preoperative diagnosis of all patients was groove pancreatitis. Histological finding was compatible with clinically diagnosed groove pancreatitis in five patients and the pathologic diagnosis of the remaining patient was adenocarcinoma of distal common bile duct. Following pancreaticoduodenectomy, four living patients experienced significant pain alleviation.
The diagnostic imaging modalities of choice for groove pancreatitis are computed tomography and endoscopic ultrasonography. If symptomatic groove pancreatitis is suspected, careful follow-up of patients is necessary and pancreaticoduodenectomy seems to be a reasonable treatment option.

Full text

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J Korean Surg Soc 2011;80:342-347
DOI: 10.4174/jkss.2011.80.5.342
ORIGINAL ARTICLE
Copyright © 2011, the Korean Surgical Society
JKSS
Journal of the Korean Surgical Society
pISSN 2233-7903ㆍeISSN 2093-0488
Received October 15, 2010, Accepted January 4, 2011
Correspondence to: Young Seok Han
Division of Hepatobiliary & Pancreas and Transplantation, Department of Surgery, Daegu Catholic University Medical Center, Catholic
University of Daegu School of Medicine, 3056-6 Daemyeong 4-dong, Nam-gu, Daegu 705-718, Korea
Tel: ＋82-53-650-4230, Fax: ＋82-53-650-4950, E-mail: hyskhk@cu.ac.kr
cc Journal of the Korean Surgical Society is an Open Access Journal. All articles are distributed under the terms of the Creative Commons
Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use,
distribution, and reproduction in any medium, provided the original work is properly cited.
Characteristic clinical and pathologic features for
preoperative diagnosed groove pancreatitis
Joo Dong Kim, Young Seok Han, Dong Lak Choi
Department of Surgery, Catholic University of Daegu School of Medicine, Deagu, Korea
Purpose: Groove pancreatitis is a rare specific form of chronic pancreatitis that extends into the anatomical area between the
pancreatic head, the duodenum, and the common bile duct, which are referred to as the groove areas. We present the diag-
nostic modalities, pathological features and clinical outcomes of a series of symptomatic patients with groove pancreatitis
who underwent pancreaticoduodenectomy. Methods: Six patients undergoing pancreaticoduodenectomy between May 2006
and May 2009 due to a clinical diagnosis of symptomatic groove pancreatitis were retrospectively included in the study.
Results: Five cases were male and one case was female, with a median age at diagnosis of 50 years. Their chief complaints
were abdominal pain and vomiting. Abdominal computed tomography, endoscopic ultrasound and endoscopic retrograde
cholangiopancreatography were performed. Preoperative diagnosis of all patients was groove pancreatitis. Histological find-
ing was compatible with clinically diagnosed groove pancreatitis in five patients and the pathologic diagnosis of the remain-
ing patient was adenocarcinoma of distal common bile duct. Following pancreaticoduodenectomy, four living patients expe-
rienced significant pain alleviation. Conclusion: The diagnostic imaging modalities of choice for groove pancreatitis are com-
puted tomography and endoscopic ultrasonography. If symptomatic groove pancreatitis is suspected, careful follow-up of
patients is necessary and pancreaticoduodenectomy seems to be a reasonable treatment option.
Key Words: Pancreaticoduodenal groove, Pancreatitis, Chronic disease, Pancreatic cancer, Pancreaticoduodenectomy
INTRODUCTION
Groove pancreatitis is a specific form of chronic pan-
creatitis that extends into the anatomical area between the
pancreatic head, the duodenum, and the common bile
duct, which is referred to as the groove areas. In 1973,
groove pancreatitis was first used to describe segmental
pancreatitis of the groove area [1].
Groove pancreatitis is not common, and only three cas-
es have been published in Korea [2-4]. Because of its rarity,
the distinct incidence of groove pancreatitis is unknown,
but it accounts for 19.5 to 24.4% of pancreaticoduodenec-
tomy performed to treat chronic pancreatitis [1,5]. Most
patients with groove pancreatitis are 40 to 50-year-old
males with a history of alcohol abuse [1,5]. The patho-
genesis is still unclear but anatomical and functional ob-
struction of the minor papilla is one of the issues
considered.
We present a series of symptomatic patients with
groove pancreatitis who underwent pancreaticoduode-

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Table 1. Patient demographics
Case Age/Sex Abd painWt lossVomitinga)
Pancreatitisb)
Alcohol Smoking
1
2
3
4
5
6
32/M
68/F
67/M
44/M
17/M
56/M
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Yes
No
No
Yes
Yes
#6
#1
#2
#3
Yes
No
Yes
Yes
No
Yes
Yes
No
Yes
Yes
No
Yes
None
#2
Abd, abdomen; Wt, weight.
a)Vomiting, by gastric outlet obstruction. b)Pancreatitis, number of admissions due to pancreatitis.
Table 2. Radiological characteristics and histologic findings
Case
Radiologic characteristics Histologic findings
CTEUS ERCPGroove fiborsisCystic changea)
Hyperplasiab)
1
2
3
4
5
6
Nonspecific
Massc)
Mass
Cystd)
Mass
Cyst
Mass
Mass
Not done
Not done
Thickeninge)
EPf), cyst
Not done
Not done
Swellingg)
Swelling
Not done
Not done
Yes No No
Cholangiocarcinoma in distal BD
Yes 0.2 cm
No0.5 cm
No
YesPseudocyst
Yes
No
No
No
No
CT, computed tomography; EUS, endoscopic ultrasonography; ERCP, endoscopic retrograde cholangiopancreatography.
a)Cystic change, cystic change of duodenal wall. b)Hyperplasia, Brunner gland hyperplasia. c)Mass, low attenuated mass lesion. d)Cyst, cystic
mass in pancreas head. e)Thickening, duodenal wall thickening. f)EP, ectopic pancreatic tissue. g)Swelling, mucosal swelling at 2nd portion
of duodenum.
nectomy, and review the diagnostic imaging modalities,
pathological features and clinical outcomes.
METHODS
Patients undergoing pancreaticoduodenectomy due to
a clinical diagnosis of symptomatic groove pancreatitis
supported by radiological imaging that included com-
puted tomography (CT), endoscopic ultrasonography
(EUS) and endoscopic retrograde cholangiopancreatog-
raphy (ERCP) were retrospectively included in the study
from May 2006 to May 2009. Groove pancreatitis was con-
firmed histologically in 5 patients, and the final diagnosis
of one patient was distal common bile duct cancer.
Collected data included demography, clinical pre-
sentation, diagnostic imaging work-up, histologic results
and clinical outcomes.
RESULTS
Clinical manifestations of patients with groove
pancreatitis (Table 1)
Six patients were included in the study. Five cases were
male and one case was female, with a median age at diag-
nosis of 50 years (range, 17 to 68 years). Among these, four
patients were heavy alcohol drinkers and smokers. All pa-
tients had epigastric or right upper quadrant abdominal
pain requiring regular non-opiate analgesia. Severe
weight loss (16 kg for 1 month) was detected in one patient.
Intermittent nausea and vomiting was featured in 3 pa-
tients and gastric outflow obstruction due to duodenal
wall thickening and swelling was inspected in these pa-
tients during endoscopic examination. Liver function test
was within normal range in all 6 patients and none were
jaundiced at presentation. Mild hyperamylasemia was de-
tected in 2 patients. Serum carcinoembryonic antigen and
CA 19-9 levels were within normal range in all patients.

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Fig. 1. Computed tomography reveals typical cystic and mass-like
lesions in head of pancreas at interface with duodenum.
Fig. 2. Computed tomography (A)
and endoscopy (B) are compatible
with groove pancreatitis, but pa-
tient’s pathologic diagnosis was
distal common bile duct cholangio-
carcinoma.
Findings of imaging studies (Table 2)
Six patients underwent a contrast-enhanced CT scan of
the abdomen which showed focal low attenuated lesion in
groove area. Such specific diagnostic features of groove
pancreatitis on CT were present in 5 patients. Cystic le-
sions in the head of pancreas at the interface with the duo-
denum were observed in 2 cases and mass-like lesions on
the head of pancreas in 3 patients (Fig. 1).
Ectopic pancreatic tissue was suspected on EUS in one
patient, but pathologic findings revealed only pancreatic
pseudocyst. ERCP didn’t show any specific features relat-
ing to groove pancreatitis.
Hypoechoic areas at the head of pancreas with loss of
duodenal wall layers at the 2nd portion of duodenum was
revealed on preoperative performed EUS in the patient
with distal bile duct cancer. And the finding by EUS was
compatible with CT. Endoscopy and EUS were performed
2 times for biopsy and the pathologic results were chronic
inflammation (Fig. 2).
Clinical outcomes
All patients underwent a pancreaticoduodenectomy.
One patient, who was a 17-year-old male, underwent a
classical Whipple procedure because his duodenal wall
was severely inflamed in the operative field and a huge
mucosal ulceration of the duodenal bulb was inspected in
preoperative endoscopic finding. Two patients expired
due to asphyxia and postoperative upper gastrointestinal
bleeding; the bleeding focus was not identified by angiog-
raphy or endoscopy. The postoperative period in the 4 sur-
viving cases was uneventful with a median hospital-
ization of 20 days (range, 14 to 21 days). After a median fol-
low-up period of 32 months (range, 18 to 53 months), the
four living patients have experienced significant pain alle-
viation and have not required any analgesia. One of the
four patients with pain relief has resumed heavy alcohol
abuse and pancreatic pseudocyst was identified in his
remnant pancreas tail.
Histologic results (Table 2)
Histologic findings of 5 cases were compatible with
clinically diagnosed groove pancreatitis. Four cases
showed chronic inflammation of the pancreaticoduodenal
interface and adjacent duodenal wall and pancreatic head,
with extensive scarring and widening of the pan-
creaticoduodenal groove (Fig. 3), and acute inflammation
of groove area and involved duodenum was shown in the

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345
Fig. 3. Gross findings. A specific form of chronic pancreatitis that
extended into anatomical area between pancreatic head,
duodenum, and common bile duct is shown.
Fig. 4. Acute inflammation of groove area is shown in histologic
examination of 17-year-old male (H&E, x40).
17-year-old male (Fig. 4). In the 68-year-old woman with-
out a history of alcoholism or smoking, histologic analysis
revealed surrounding foci of adenocarcinoma of the distal
common bile duct. Brunner’s gland hyperplasia was seen
in one case. Two cases revealed cystic change in the duode-
nal wall and pancreatic pseudocyst extended into the duo-
denal wall in one case.
DISCUSSION
The pathogenesis of groove pancreatitis remains
unclear. Anatomical or functional obstruction of the minor
papilla is one of the issues considered. It is explained that
Brunner gland hyperplasia and stasis of pancreatic juice in
the dorsal pancreas leads to pancreatitis in the groove area
[1]. And anatomical factors, including a duodenal bud and
ectopic pancreas, are other possible reasons for groove
pancreatitis [6]. We experienced six patients diagnosed
with groove pancreatitis by clinical diagnostic modalities
and pathologic examination. Ectopic pancreas in groove
area was suspected by EUS but was not confirmed by
pathology.
In 3 of the 5 cases (60%), cystic changes in the duodenal
wall including one pseudocyst were detected. Thickening
and scarring of the duodenal wall close to the minor papil-
la usually causes stenosis of the second portion of the
duodenum. In three cases, gastric outlet obstruction de-
veloped due to stenosis of the involved duodenum. Cystic
change in the thickened duodenal wall is a characteristic
feature and intraduodenal cysts are identified in 49% of
patients with groove pancreatitis [5]. Lymphocyte infiltra-
tion, fibrosis or scarring in the groove area are also sig-
nificant [1,7]. In the present study, these histologic features
were confirmed in 4 cases except in one case with distal
common bile duct cancer.
The clinical manifestations of groove pancreatitis com-
prise upper abdominal pain, weight loss, postprandial
vomiting and nausea due to duodenal stenosis, but jaun-
dice is rare [7-9]. The chief complaint of all cases was epi-
gastric or right upper quadrant abdominal pain in the
present study. Clinical complications associated with
groove pancreatitis are related to inflammatory changes
affecting the duodenal wall. And major gastrointestinal
hemorrhage, perforation, chronic debilitating abdominal
pain, recurrent pancreatitis, duodenal stenosis, and, albeit
a small risk, malignant transformation of ectopic pancreas
have been reported [1,8].
Upper endoscopy often shows an inflamed and poly-
poid duodenal mucosa with stenosis of the duodenal lu-
men [10]. EUS reveals smooth stenosis of the common bile
duct; Santorini’s duct is usually undetectable. Duct-pene-
trating signs are evident in the irregular hypoechoic mass
[9]. In our experience, EUS was also effective in diagnosing

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groove pancreatitis. However, EUS makes insertion im-
possible due to duodenal stenosis and the accuracy of EUS
is dependent on operator and experience. CT scan for
groove pancreatitis reveals a hypodense, poorly enhanced
mass between the pancreatic head and a thickened duode-
nal wall. Cystic lesions and a thickened duodenal wall are
also useful indicators of groove pancreatitis on dynamic
CT images [11]. Endoscopic retrograde cholangiopancrea-
tography reveals tapering of the lower bile duct [9,10].
When the duodenum of patients with groove pancreatitis
is too narrow to perform gastrointestinal endoscopy and
distinction between groove pancreatitis and pancreatic
malignancy is difficult, magnetic resonance chol-
angiopancreatography is a useful diagnostic option [12].
Clinicians must consider peripancreatic cancer for a dif-
ferential diagnosis of groove pancreatitis. The appearance
of groove pancreatitis may resemble: 1) pancreatic dis-
eases, such as acute pancreatitis; exophytic pancreatic
ductal adenocarcinoma; or neoendocrine tumors; 2) bile
ducts diseases such as cholangiocarcinoma and chol-
edochal cysts; and 3) duodenal diseases. Other differential
diseases include autoimmune pancreatitis and duodenal
hamartoma [6]. In our experience, an older female without
a history of alcoholism was diagnosed with groove pan-
creatitis by preoperative imaging studies including CT
and EUS. Endoscopic biopsy demonstrated chronic
inflammation. However, the final pathologic diagnosis
was cholangiocarcinoma of distal common bile duct.
Accordingly, careful follow-up of patients with a diag-
nosis of groove pancreatitis is necessary, because some
conditions closely resemble peri-pancreatic carcinoma.
And in cases where the diagnosis is in doubt, there are lo-
cal complications, or when conservative treatment is in-
effective, a pancreaticoduodenectomy with histological
examination should be performed. In patients with groove
pancreatitis, resection is often performed for the diagnosis
of a peripancreatic malignancy [13].
Conservative treatments are to stop tobacco/alcohol
consumption, recovery of pancreatic function, and
analgesics. However, such treatments are only tempora-
rily effective, as a rule [14]. Isayama et al. [15] reported the
treatment of groove pancreatitis by endoscopic stenting of
the minor papilla, but the long-term clinical course re-
mains obscure.
Surgery is the treatment of choice when symptoms do
not improve, or when the condition is too difficult to dis-
tinguish from pancreatic carcinoma. In a study by Rahman
et al. [16], body weight increased and chronic abdominal
pain was relieved in all patients who underwent
pancreatoduodenectomy. Complete pain relief was re-
ported in 76% of the patients after pancreatoduodenec-
tomy [17]. There are three cases of 4 living patients who re-
covered from their pain after successful pancreaticoduo-
denectomy. The preservation of the pylorus during pan-
creaticoduodenectomy is not always feasible. We per-
formed the Whipple procedure on one patient. We could
not preserve the duodenal bulb and pylorus due to severe
inflammation and mucosal erosion of his duodenal bulb.
And we experienced two fatal complications including as-
phyxia and postoperative gastrointestinal bleeding. So,
morbidity and mortality of pancreaticoduodenectomy
should be considered.
In conclusion, patients with groove pancreatitis have
clinical characteristics similar to those of chronic pan-
creatitis. The diagnostic imaging modalities of choice are
computed tomography and endoscopic ultrasonography.
And careful follow-up of patients is necessary if groove
pancreatitis is suspected, because some conditions closely
resemble peri-pancreatic carcinoma. Based on our surgical
experience, pancreaticoduodenectomy seems to be a rea-
sonable treatment option in patients with groove
pancreatitis.
CONFLICTS OF INTEREST
No potential conflict of interest relevant to this article
was reported.
REFERENCES
1. Stolte M, Weiss W, Volkholz H, Rösch W. A special form of
segmental pancreatitis: "groove pancreatitis". Hepatoga-
stroenterology 1982;29:198-208.
2. Hwang JY, Park KS, Cho KB, Hwang JS, Ahn SH, Park SK,
et al. Segmental groove pancreatitis: report of one case.