Illustrated Encyclopedia of Human Anatomic Variation: Opus IV: Organ Systems: Digestive System and Spleen

Pancreas

Ronald A. Bergman, PhD
Adel K. Afifi, MD, MS
Ryosuke Miyauchi, MD
Peer Review Status: Internally Peer Reviewed

One of the most interesting but rare variations of the pancreas is the condition known as the annular pancreas. The duodenum (usually its descending part) is surrounded by a ring of pancreatic tissue continous with the head of the pancreas. There may be a constriction of the duodenum at the location of the ring, with dilations above and below. It is generally considered that the ventral rudiment of the pancreas consists of a right and left part. The left part usually atrophies but may persist, or the right half may exhibit excessive growth and surround the pancreas. The duct contained in the ring joins the ductus pancreaticus near the duodenum.

The tail of the pancreas is sometimes bifid, and the part of the head lying behind the mesenteric vessels may be separate from the remainder of the gland, forming what is called the lesser (accessory) pancreas.

Various examples of an accessory pancreas have been described after the initial description by Klob in 1859. They may occur in the mesentery of the small intestine, the wall of the duodenum, the upper part of the jejunum, or more rarely, in the wall of the stomach, ileum, gallbladder, or spleen. They are generally situated either in the submucosa or the subserous coat, but may extend into the muscular layer. An accessory pancreas was found near the origin of the inferior mesenteric artery in an 11-year old boy. The size of these masses varies in diameter, from a few millimeters to 5cm and their own ducts. The masses may contain pancreatic islet cells. In a few cases, some pancreatic tissue has been found at the blind end of intestinal (Meckel's) diverticula. They may appear in any derivative of the foregut, from stomach to the ileal (Meckel's) diverticulum including the spleen and gallbladder, but not the large intestine. They are most common in the duodenum.

Pancreatic divisum occurs in development when the dorsal and ventral parts of the pancreas fail to fuse so that the drainage of the gland is mainly through the accessory papilla. It was found in 3/169 patients. In patients with recurrent pancreatitis the incidence was 25.6%/ 78 patients. Autopsy studies suggest that pancreas divisum is the most common congenital variation of the organ. Divided pancreas differs from the accessory in that a mass of the pancreas becomes separated from the main gland, connected only by a duct. This occurs most often in the region of the tail (sometimes extending into the spleen) or of the uncinate process, forming what is termed a "lesser pancreas." According to Anson, "Variations in the direction of the body are numerous. It may be transverse, ascending, or bent in various ways. Numerous variations in the ducts can be understood from their complicated development. The accessory pancreatic duct in the fetus is as large as the pancreatic duct, the preponderance of the latter being established later. The accessory duct in the adult may be larger than usual, and retain its primitive drainage, or even drain the entire gland in rare cases where the pancreatic duct is absent.

"A sphincteric arrangement of the muscle tissue at the end of the accessory pancreatic duct has been described (Helly). The accessory duct may be rudimentary or (rarely) absent. Similar variations occur in the pancreatic duct. Rarely the pancreas may open into the duodenum by three ducts. Abnormalities of the pancreas are often associated with duodenal diverticula."

Other studies of variations in the pancreatic ducts indicate that in as many as 40% of adults the accessory (Bernards' or Santorini's) duct is not functionally joined to the chief or primary pancreatic duct. In 15% of cases there is a dual drainage from both ducts, in 7% there is a dual drainage and a functional connection between the two ducts, and in 2% the accessory duct does not drain into the duodenum but into the primary duct.

Bidloo, 1685, first described the duodenal mucosal papilla common to both the bile and pancreatic ducts. Graaf, 1671, had previously reported that the pancreas might present two or even three ducts, contrary to prevailing opinion. A number of 17th century investigators involved in pancreatic structure are provided in the reference list. Following the work of Bidloo, Haller, Tiedemann, Bécourt, Bernard, and Langerhans reported variations in the duct systems.

Embryological development of the pancreas

Pancreatic Ducts

Pancreatic and Common Bile Ducts

Annular Pancreas

Annular Pancreas

Accessory Pancreas

References

Ahmed, A., Chan, K.H. and I.S. Song (1982) Annular pancreas. Compt. Assist. Tomogr. 6(2):409- 411.

Albrecht, E. (1901) Ein Fall von Pankreasbildung in einem Meckelschen Divertikel. Münchener Med. Wochenschrift 48:20612062.

Albrecht, E. und L. Artz. (1910) Beiträge zur Frage der Gewebsverirrung: II über die Bildung von Darmdivertikeln mit dystrophischem Pankreas. Frankfurter Zeitschr. f. Path. 4:167-185.

Alessandri, R. (1908) A case of accessory pancreas. Ann. Ital. di Chir. 7:1.

Anderson, J.R. and H. Wapshaw. (1951-52) Annular pancreas. Brit. J. Surg. 39:43-49.

Anson, B.J., Ed. (1966) Morris' Human Anatomy, 12th ed., The Blakiston Division, McGraw-Hill Book Company, New York.

Anson, B.J., Lyman, R.Y. and H.H. Lander. (1936) The abdominal viscera in situ. A study of 125 consecutive cadavers. Anat. Rec. 67:17-21.

Askanazy, M. (1923) Zur Pathogenese der Magenkrebse und über ihren gelegentlichen Ursprung aus angeborrenen epithelialen Keimen in der Magenwand. Dtsch. Med. Wochenschr. 49:3-6, 49-51.

Baldwin, W.M. (1910) A specimen of annular pancreas. Anat. Rec. 4:299-304.

Baldwin, W.M. (19 10) An adult human pancreas showing an embryological condition. Anat. Rec. 4:21- 22.

Barbosa, J.J. de C., Dockerty, M.B. and J.M. Waugh. (1946) Pancreatic heterotopia: Review of literature and report of 41 authenticated surgical cases, of which 25 were clinically significant. Surg. Gynecol. Obstet. 82:527-542.

Barcaroli, 1. (193 1) Sur le pancreás accessoire. Ann. Ital. di Chir. 10:969.

Baron, -. (1826) Vice de conformation. Transposition compléte des viscères abdominaux et thorachiques. Arch. Gén. Méd. 10:131.

Bartholinus, T. (1656) Anatomia. J. Soury. Dordrecht.

Bécourt, P.J.G. (1830) Recherches sur le pancréas. F.G. Levrault, Strasbourgh.

Benjamin, A.E. (1918) Accessory pancreas with intussusception. Ann. Surg. 67:293-298.

Bernard, C. (1856) Mémoire sur le pancréas. J.-B. Baillière. Paris.

Beutler, A. (192 1) über blastomatöses Wuchen von Pankreaskeimen in der Magenwand. Virchow's Arch. f. Path. Anat. u. Physiol. u. f. Klin. Med. 232:341-349.

Bickford, B.J. and J.C.F.L. Williamson. (1951-52) Annular pancreas. Brit. J. Surg. 39:49-52.

Bidloo, G. (1685) Anatomia humani corporis. Vid. J. à Someren. Amstelodami.

Bize, -. (1904) Etude anatomo-clinique des Pancréas accessoires situés à 1'extremite d'un diverticule intestinal. Rev. d'Orthop. 5:149-150.

Bookman, M.R. (193 2) Carcinoma of the duodenum originating from aberrant pancreatic cells. Ann. Surg. 95:464-467.

Bosworth, B.M. and H.D. Stein. (1947) Intussuseption in adults: Report of a case due to aberrant pancreas. Am. J. Surg. 74:801-804.

Boyden, E.A. (1937) The sphincter of Oddi in man and certrain representative mammals. Surgery 1:25-37.

Brandt, G. (1984) Die Gefässarchitekur des humanen kaudalen Pancreas. Anat. Anz. 157:73-81.

Cafritz, E.A. (1929) Accessory pancreatic tissue: A case report. Southern Med. J. 22:833-835.

Calas, F., Bouchet, Y. and R. Martin. (1954) Etude morphologique des canaux de la tête du pancreas. Assoc. Anatomistes Comptes Rendus 41:866-876.

Carwardine, G.F. and A.R. Short. (1913) The surgical significance of the accessory pancreas. Ann. Surg. 57:653-657.

Cave, H.W. (1928) Aberrant pancreatic tissue simulating duodenal ulcer. Am. J. Surg. 5:407.

Chapman, J.L. and H.W. Mossman. (1943) Annular pancreas accompanied by aberrant pancreatic nodule in duodenum. Am. J. Surg. 60:286-288.

Charpy, A. (1898) Variétiés et anomalies des canaux pancréatiques. J. de l'Anat. et Physiol. 34:720.

Cogniauz, P. (1928) Contribution a Petude des pancréas aberrants. Arch. Franco-Belges de Chir. 31:307-317.

Cohen, H. (1922) Accessory pancreas with ulcer of pylorus. Surg., Gynecol. Obstet. 34:385-387.

Cotton, P.B. (1980) Congenital anomaly of pancreas divisum as cause of obstructive pain and pancreatitis. Gut 21:105-114.

Cox, W.W. (1929) Aberrant pancreas in stomach wall. J. Med. Soc. New Jersey 26:467.

Cruveilhier, -. (1843) Terminaison du canal pancréatique dans le duodenum par un orifice unique et isolé de l'orifice du canal cholédeque. Bulletins et Mem. de la Société Anatomique de Paris XVIII(9):262.

Cruveilhier, J. (1861) Traité d'anatomie descriptiv, 4th ed. P. Asselin. Paris.

Culpeper, N. and A. Bole (1668) Anatomy. London.

De Graaf, R. (1671) Tractatus anatomico-medicus de succi pancreatici natura et usu. Ex off. Hackiana. Lugd. Bat.

Gibson, C.L. (1912) Accessory pancreas in the gastro-intestine tract. Med. Rec. 83:426-427.

Glinski, LK. (1901) Zur Kenntnis des Nebenpankreas und verwanter Zustände. Virchow's Arch. f. Pathol. Anat. u. Physiol. u. f. Klin. Med. 164:132-146.

Goldyne, A.J. and E, Carlson. (1946) Annular pancreas causing duodenal obstruction. Am. J. Surg. 71:429-433.

Griep, K. (1920) Zur Kasuistik und klinik des accessorischen Pankreas in der Magenwand. Med. Klin. 16:877-878.

Griep, K. (1926) Zur klinischen Bedeutung des adzessorischen Pankreas in der Magenwand. Zentralblatt f. Chir. 53:2147-2150.

Gross, R.E. and T.C. Chisholm. (1944) Annular pancreas producing duodenal obstruction: Report of a successfully treated case. Ann. Surg. 119:759-769.

Haller, A. (1764-1766) elementa physiologiae corporis humani. Berne.

Hamburger, O. (1892) Zur Entwickelung der Bauchspeichel drüse des Menschen. Anat. Anz. 7:707.

Hedinger, -. (1906) Fall von Meckel'schen Divertkel mit Pankreasgeweb und Brunner'sschen Drusen an der Spitze derselben. Correspondence-Bl. f. Schweitzer Aerzte 36:395-396.

von Heinrich, H. (1909) Ein Beitrag zur Histologie des sogen. akzessorischen Pankreas. Virchow's Arch. f. Path. Anat. u. Physiol. u. f. Klin Med. 198:392-422.

Helly, K.K. (1898) Beiträge zur Anatomie des Pankreas und seiner Auführungsgänge. Arch. f. mikr. Anat. 52:773.

Helly, K.K. (1899) Die Schliessmuskulatur an den Mündengen des Gallen - und der Pankrasgänge. Arch. Mikrosk. Anatomie. 54:614-621.

Henle, F.G. J. (1873) Handbuch der Systematischen Anatomie des Menschen. F. Vieweg u. Sohn. Braunschweig.

Heymann, R.L. and T.J. Whelan, Jr. (1967) Annular pancreas: Demonstration of the annular duct on cholangiography. Ann. Surg. 165:470-472.

Horgan, E.J. (192 1) Accessory pancreatic tissue: Two cases. Arch. Surg. 2:521-534.

Howell, L.M. (1946) Meckel's diverticulum: A consideration of the anomaly with a review of sixty-one cases. Ann. J. Dis. Child. 71:365-377.

Hulst, J.P.L. (1909) Ueber einem Darmdivertikel gelagerten Pankreaskeirn mit sekundarer Invagination. Centralbl. f. AlIg. Path. u. Path. Anat. 20:12-15.

Hunt, V.C. and H.T.S. Bonesteel. (1934) Meckel's diverticulum containing aberrant pancreas. Arch. Surg. 28:425-439.

Hyrtle, J. (1865) Ein Pancreas accessorum und pancreas divisim. Sitzungsberichte de Kaiserlichen Akad. der Wissenschaften. Weiner Acad. Sitzungsberichte. Math.-Natur kl. 52(l):275-280.

Jackson, C.H. (1905) On the topgraphy of the pancreas in the human fetus. Anat. Anz. 27:488-510.

Job, T.T. (1926) Relationship of common bile and pancreatic ducts. Anat. Rec. 32:212-213.

Keyl, R. (1924) Ein Fall von Ringpankreas. Anat. Anz. 58:209-218.

King, E.S.J. and P. MacCallum. (1934) Pancreatic tissue in the wall of the stomach. Arch. Surg. 28:125-138.

Klob, J. (1859) Pancreas accessorium. Zeitschrift der Kaiserl. Königl. Gesellschaft der Aerzte zu Wien 15 (47):732.

Klob, J. (1859) Pancreas includens lien succenturiatum. Zeitschrift Königl. Gesellschaft der Aerzte zu Wien 15(47):732-733.

Kreilkamp, B.L. and E. A. Boyden. (1946) Variability in the composition of the sphincter of Oddi: A possible factor in the pathologic physiology of the biliary tract. Anat. Rec. 76:485-497.

Kubota, K. (1955) A case of rare type of an accessory pancreas. Folia Anat. Jpn. 27:193-196.

Langerhans, P. (1896) Beiträge zur mikropische Anatomie der Bauchspeicheldrüse. G. Lang. Berlin.

Lecco, T.M. (1910) Pancrease anulare. Wien. Klin. Wochenschrift 23:875.

Lecco, T.M. (1910) Zur Morphologie des Pankreas annulare. Sitzungberichte de Kaiserlichen Akademie der Wissenschaften. 69:391-406.

Lehman, E.P. (1942) Annular pancreas as a clinical problem. Ann. Surg. 115:574-585.

Letulle, M. (1900) Pancréas surnuméraires. Société Biol. Comptes Rendus Hebdomadaires des Séances et Mémoires 52:233-235.

Lordy, C. (1930) Accessory pancreas in duodenum due to persistence of left ventral embryonic pancreas. Ann. de Fac. de Med. de São Paulo. 5:91.

Meckel, J.F. (1812-1816) Handbuch der pathologischen Anatomie. C.H. Reclam. Leipzig.

Milbourn, E. (1950) On the excretory ducts of the pancreas in man, with special reference to their relations to each other, to the common bile duct and to the duodenum. Acta Anat. 9:1-34.

Montgomery, E. (186o-61) Two specimens of accessory pancreas. Trans. Path. Soc. Lond. 12:130.

Moore, R.A. (1929) Accessory pancreases: Report of a case with discussion of their pathology and origin. Am. J. Pathol. 5:407-414.

Müller, G.P. (1904) Accessory pancreas in posterior wall of stomach. Proc. Path. Soc. (Philadelphia) 7:226.

Münch, H. (1925) Pankreaskeime im pyloris. Mitt. a. d. Grenzgeb. d. Med. u. Chir. 38:538-542.

Von Muralt, J. (1677) Vamde mecum anatomicum. Typ, D, Gessner. Tiguri.

Nauwerck, C. (1892) Ein Nebenpancreas. Beitr. z. Path. Anat. u. z. Alleg. Path. 12:29-32.

Nazari, A. (1909) Aberrant pancreas and diverticulum of Meckel. Boll d. Roy. Accad. Med. di Roma. 35:246.

Neumann, E. (18 7 0) Nebenpancreas in Darmdiverikel. Arch. d. Heilkunde. 11:200.

Nieuwenhuijse, P. (1919) Over het pancreas accessorium. Nederl. Tijdschr. v. Geneesk. 4:2106- 2113.

Odgers, P.N.B. (1930) Some observations on the development of the vertical pancreas in man. J. Anat. 65:1-7.

Opie, E.L. (1910) Diseases of the Pancreas, 2nd ed., J.B. Lippincott Co., Philadelphia.

Pathak, A.K. (1978) Annular pancreas. Proc. Anat. Soc. India #77, 26th Ann. Conf., 1977. J. Anat. Soc. of India 27:43-44.

Przystasz, T. (1980) Additional pancreas. Folia Morphol. (Warsaw) 39:341-345.

Reitmann, K. (1903) Zwei Fälle von accessorischem Pankreas. Anat. Anz. 23:155-157.

Reynier, - et -. Masson. (1909) Sténose pyloirque due à un lobuble pancréatique aberrant. Acad. de Méd. Bull. Paris 62:100-106.

Richter, J.M., Schapiro, R.M., Mulley, A.G. and A.L. Warshaw. (198 1) Association of pancreas divisum and pancreatitis, and its treatment by sphincteroplasty of the accessory ampulla. Gastroenterology 81:1104-1110.

Rienhoff, W.F., Jr. and K.L. Pickrell. (1945) Pancreatitis. An anatomic study of the pancreatic and extrahepatic biliary systems. Arch. Surg. 51:205-219.

Ritter, L. (1921) Zum klinischen Bilde und Sitz versprengter Pancreaskeime. Beitr. Klin. Chir. 124:157-172.

Roach, J.F. and M.H. Poppel. (1946) The roentgen demonstration of an aberrant pancreatic nodule in the stomach. Report of three cases. Am. J. Roentgenol. 56:586-589.

Robertson, W.E. (1904) Aberrant pancreas in wall of jejunum. Proc. Path. Soc. Philadelphia 7:228.

Ruge, E. (1908) Beiträge zur chirurgischen Anatomie der grossen Gallenwege (Ductus hepaticus, cysticus, choledochus und pancreaticus). Arch. Klin. Chir. 87:47-78.

Sandifort, Ed. (1777) Ductus pancreaticus duplex. p. 127. Observationes Anatomico-Pathologicae, Apud P.v.d. Eyk et D. Vygh, Leiden.

Sappy, M.P.C. (1889) Traité d' anatomie descriptive. V.-A. Delahaye & Cie. Paris.

Schaefer, J.H. (1926) The normal weight of the pancreas in the adult human being: A biometric study. Anat. Rec. 32:119-132.

Singh, I. (1956) Observations on the mode of termination of the bile and pancreatic ducts: Anatomical factors in pancreatitis. J. Anat. Soc. India 5:54-60.

Smetana, H. (1933) Ein Beitrag zur Kenntnis der Missbildungen des Pankreas. Beitrage zur Path. Anat. (Ziegler) 80:239-256.

Ssokolow, P.A. (1930) Zu Frage über das Nebenpankreas. Anat. Anz. 70:234-241.

Stelmasiak, M. and J. Karski. (1973) Morphology of the orifices of the common bile duct and pancreatic ducts in man. Folia Morphol. (Warsaw) 32:287-295.

Stelmasiak, M. and J. Karski (1973) Relation of the accessory pancreas duct to the duodenal muscularis in man. Folia Morphol. (Warsaw) 32:407-411.

Sterling, J.A. (1954) The common channel for bile and pancreatic ducts. Surg., Gynecol. Obstet. 98:420-424.

Sugawara, K. and I. Shibata. (1925) Ein Fall von Pancreas annulare. Folia Anat. Jpn. 3:239-242.

Sussi, L. (1930) Accessory pancreas. Policlinico (Sez. Chir.) 37:448.

Sybirska-Szczepanska, B. (1964) Very rare localization of an accessory pancreas. Folia Morphol. (Warsaw) 23:432-435.

Symington, J. (1885) A rare abnormality of the pancreas. J. Anat. Physiol. 19:292.

Swalve, B. (1667) Pancreas pancrene. E. Weyerstraten. Amstelodami.

Thelemann, -. (1906) über accessorisches Pancreas in der Magenwand. Deutsche Zeitschr. f. Chir. 85:692-709.

Thomson, A. (1908) Diverticula of the alimentary tract, with particular reference to those met within the ileum resulting from an accessory pancreas and from tuberculosis. Medico-Chir. Trans. Edinb. 27:118-129.

Thorel, C. (1903) Histologisches über Nebenpancreas. Virchow's Arch. f. Path. Anat. u. Physiol. u. f. Klin. Med. 173:182-301.

Tiedemann, F. (1819) Sur les différences que le canal excríter du pancréas présente dans l'homme et dans les mammifères. J. compl. du dict. d. sc. Méd. 4:330.

Tiedemann, F. and L. Gmelin. (1826) Die Verdauung nach Versuchen. K. Groos. Leopzig.

Vandendrop, F. (1928) Note sur un pancréas gastrique accessoire. Soc. de Biol., Comptes Rendus Hebdomadaires. 99:795-796.

Vandendrop, F. (1929) Note sur an pancréas accessoire. Soc. de Biol., Comptes Rendus Hebdomadaires. 100:658-659.

Veslingius, J. (1647) syntagma anatomicum, typ. P. Frambotti. Patavii.

Villemin, F. et C. Gardnier. (1912) Anomalie duodeno-pancréatitque chez Phomme, par plissement primitif de Panse duodénale. Bull. et Méms. de la Soc. d'Anthrop. de Paris. 3:88-94.

Wagner,-. (1862) Accessoriches Pankreas in der Magenwand. Arch. d. Heilkunde 3:283.

Warthin, A.S. (1906) Two cases of accessory pancreas (omentum and stomach). Physician & Surgeon 6:22-37.

Weidman, F.D. (1913) Aberrant pancreas in the splenic capsule. Anat. Rec. 7:133-139.

Weishaupt, E. (1917) über Adenomyome und Pankreas Gewebe im Magen und Dunndarm mit Beschreibung eines Falls von Kongenitalem Duodenaladenomyom. Virchow's Arch. f. Path. Anat. u. Physiol. u. f. Klin. Med. 223:24-33.

Welsch, C.L. (1697) Tabulae anatomicae. H.C. Cröker. Lipsaie.

Wohlwill, F. (1929) Ulcus pylori und adzessorischer Pankreaskeim. Klin. Wochenschrift 8(12):2137-2138.

Wright, J.R. (1901) Aberrant pancreas in region of umbilicus. J. Boston Soc. Med. Sci. 5:497.

Zenker, F.A. (1861) Nebenpancreas in der Darmwand. Arch. Pathol. Anat. Physiol. Klin. Med. 21:369-376.

Section Top | Title Page

URL: http://www.anatomyatlases.org/