Skip to Main Content


  • • Ring of pancreatic tissue from the head of the pancreas surrounds the descending duodenum, leading to obstruction, presenting either in infancy or adulthood

    • Vomitus is bilious if obstruction is distal to the ampulla of Vater

    • Air in the stomach and duodenum proximal to the obstruction on abdominal x-ray (double bubble sign)




  • • Rare congenital condition in which a ring of pancreatic tissue from the head of the pancreas surrounds the descending duodenum

    • The abnormality usually presents in infancy as duodenal obstruction with postprandial vomiting

    • There is bile in the vomitus if the constriction is distal to the entrance of the common bile duct

    • Occasionally, annular pancreas will present in adults with similar symptoms


Symptoms and Signs


  • • Upper GI obstruction

    • Vomiting

    • Upper GI bleeding

    • Epigastric pain


Laboratory Findings


  • • Hypochloremic metabolic alkalosis

    • Hypokalemia


Imaging Findings


  • Abdominal x-ray: Dilated stomach and proximal duodenum (double bubble sign) and little or no air in the rest of the small bowel

    Upper GI contrast radiography: Narrowing of the duodenum where it is encircled by the pancreatic head, with proximal dilation

    ERCP: Pancreatic duct in head of pancreas encircling duodenum


  • • Signs and symptoms of upper GI obstruction should prompt radiographic imaging, which may suggest duodenal obstruction

    • Always consider annular pancreas as a cause of duodenal obstruction

    • May cause peptic ulcer disease or chronic pancreatitis in an adult


Rule Out


  • • Other causes of duodenal obstruction

    • -Duodenal tumors

      -Pancreatic head masses

      -Duodenal atresia (infant)


  • • Abdominal x-ray

    • Upper GI contrast radiography

    • ERCP confirms the diagnosis but is not necessary


When to Admit


  • • All symptomatic cases


  • • Correction of fluids and electrolytes

    • The obstructed segment should be bypassed by a duodenojejunostomy

    • The obstructing pancreas should not be resected; high risk for pancreatic fistula






  • • All cases in children

    • All symptomatic cases in adults




  • • Chronic pancreatitis

    • Peptic ulcer disease

    • Obstruction

    • Bleeding




  • • Excellent after surgical bypass of obstruction



Chen YC et al. Symptomatic adult annular pancreas. J Clin Gastroenterol. 2003;36:446.  [PubMed: 12702992]
McCollum MO et al. Annular pancreas and duodenal stenosis. J Pediatr Surg. 2002;37:1776.  [PubMed: 12483656]

Want remote access to your institution's subscription?

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.


About MyAccess

If your institution subscribes to this resource, and you don't have a MyAccess profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.

Subscription Options

AccessSurgery Full Site: One-Year Subscription

Connect to the full suite of AccessSurgery content and resources including more than 160 instructional videos, 16,000+ high-quality images, interactive board review, 20+ textbooks, and more.

$995 USD
Buy Now

Pay Per View: Timed Access to all of AccessSurgery

24 Hour Subscription $34.95

Buy Now

48 Hour Subscription $54.95

Buy Now

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.