Groove Pancreatitis

Groove pancreatitis (paraduodenal pancreatitis) is a segmental chronic pancreatitis involving the pancreaticoduodenal groove between the pancreatic head, duodenum and common bile duct.

• Mainly affects middle aged men (40 to 50 years) with chronic alcohol use and smoking.
• Associated with duodenal wall anomalies: heterotopic pancreas, Brunner gland hyperplasia, duodenal diverticulum, pancreas divisum, minor papilla dysfunction.
• Pure form involves only the groove, and segmental form involves the pancreatic head.
• Pathology: fibrosis with inflammatory scarring in the groove, cystic degeneration of the duodenal wall, myoadenomatosis.
• Complications: duodenal stenosis, common bile duct stricture with jaundice, chronic pain.
• Mimics pancreatic head adenocarcinoma.

• Upper abdominal pain (often postprandial), nausea, vomiting from duodenal stenosis, weight loss.
• Jaundice in 10 to 30%.
• Recurrent acute pancreatitis.
• History of alcohol misuse; normal or mildly raised pancreatic enzymes and CA 19-9.

• Contrast CT: hypoattenuating soft tissue in the groove with delayed enhancement, duodenal wall thickening, cysts in the duodenal wall or groove, common bile duct narrowing, pancreatic head normal or minimally enlarged.
• MRI/MRCP: T2 hyperintense cystic spaces in the groove, T1 hypointense groove tissue; gradual delayed enhancement.
• Endoscopic ultrasound with fine needle biopsy: fibrosis, inflammation, absence of malignant cells; also shows duodenal cysts.
• Upper endoscopy: duodenal narrowing, mucosal polypoid change.
• CA 19-9, IgG4 to exclude autoimmune pancreatitis.
• Exclude carcinoma, duodenal neoplasm, cholangiocarcinoma; sometimes only resolved by pancreaticoduodenectomy.

• Conservative treatment first: strict alcohol abstinence, smoking cessation, analgesia (paracetamol, tramadol; avoid prolonged opioids), pancreatic enzymes (lipase 25,000 to 50,000 units per meal), small frequent meals, nutritional support, proton pump inhibitor.
• Octreotide 100 micrograms SC three times daily may relieve pain in selected patients.
• Endoscopic therapy: cyst drainage, biliary stenting or dilatation of strictures, minor papilla sphincterotomy for pancreas divisum, duodenal dilatation (limited success).
• Surgery for refractory symptoms, duodenal obstruction, biliary obstruction or inability to exclude malignancy: pancreaticoduodenectomy (Whipple procedure), the definitive treatment with symptom relief in over 80%; pylorus preserving variants.
• Gastrojejunostomy and choledochojejunostomy are palliative alternatives with less durable benefit.
• Follow up for diabetes, exocrine insufficiency, and nutritional status.