Anomalous Pancreaticobiliary Ductal Union

Naira Sultan Khuroo
, Mohammad Sultan Khuroo
, Mehnaaz Sultan Khuroo
Digestive Diseases Centre, Dr. Khuroo’s Medical Clinic;
Department of Pathology,
Sher-e-Kashmir Institute of Medical Sciences. Srinagar, Kashmir, India
Context Tropical calcific pancreatitis is unique to developing countries with of unknown origin. Objective We evaluated the pattern
of pancreaticobiliary ductal union in patients with tropical calcific pancreatitis. Patients Twenty-one patients with tropical calcific
pancreatitis were compared to 174 control subjects with no pancreaticobiliary disease and 35 patients with alcohol-induced chronic
pancreatitis. Main outcome measure Two experienced people, blinded to the results, evaluated the pattern of pancreaticobiliary
ductal union. Pancreaticobiliary ductal unions were classified as: separate ducts (no union), a short common-channel (length less
than 6 mm), a long common-channel (length ranging 6-15 mm) and anomalous pancreaticobiliary ductal union (length greater than
15 mm). Anomalous union was defined as P-B type when the pancreatic duct appeared to join the bile duct and B-P type when the
bile duct appeared to join the pancreatic duct. Any disparities between the two investigators were sorted out by mutual discussion.
Results Pancreaticobiliary ductal union in tropical calcific pancreatitis patients as compared to those in the control group was as
follows: separate ducts, 23.8% vs. 49.4% (P=0.036); a short common-channel, 4.8% vs. 28.7% (P=0.017); a long common channel,
33.3% vs. 18.4% (P=0.144) and anomalous pancreaticobiliary ductal union, 38.1% vs. 3.4% (P<0.001). The B-P pattern of
anomalous pancreaticobiliary ductal union was more frequent in tropical calcific pancreatitis than in the control group but there was
no statistical significance (P=0.103). The angle of the pancreaticobiliary ductal union in the tropical calcific pancreatitis group was
88.1±36.2° as compared to 20.0±11.5° in control group (P<0.001). Alcohol-induced chronic pancreatitis (No. 35) predominantly had
either separate ducts (65.7%) or a short common channel (25.7%). Conclusion We concluded that patients with tropical calcific
pancreatitis in Kashmir had anomalous pancreaticobiliary ductal union, predominantly of B-P type with a wide angle of ductal union
more frequently. This may be related to the etiology of tropical calcific pancreatitis in such regions.
Tropical calcific pancreatitis is a disease with unique
clinical and radiological features and is prevalent in
many tropical countries including south India, Sri
Lanka, and many African and Asian countries [1, 2, 3,
4, 5, 6, 7, 8]. The disease is reported to affect younger
age groups; it is characterized by rapid progression
associated with severe pancreatic damage and multiple
large ductal calculi, and the absence of a history of
alcoholism or biliary tract disease. Abdominal pain and
diabetes are dominant clinical manifestations.
Steatorrhea and malnutrition may be associated
features [9, 10]. The pancreas shows atrophy, markedly
dilated pancreatic ducts and large intraductal calculi. A
pancreatic neoplasm is a common occurrence in these
patients [11]. Over the years, there has been a trend to
occurrence in older age groups and it has been reported
in countries outside the tropics [12, 13]. The etiology
of tropical calcific pancreatitis in such countries
remains obscure.
Pancreaticobiliary ductal union is the confluence of the
pancreatic duct and the bile duct; this union shows
many variations [14, 15]. Patterns of pancreaticobiliary
ductal union have been associated with many
pancreatic and biliary diseases [16, 17, 18, 19, 20]. The
relationship of the patterns of pancreaticobiliary ductal
union with tropical calcific pancreatitis has not been
studied. We wish to report on the pattern of
pancreaticobiliary ductal union in patients from
Kashmir, India having tropical calcific pancreatitis.
This was a nested case control study which was
designed to study the pattern of pancreaticobiliary
ductal union in 21 patients from Kashmir, India having
tropical calcific pancreatitis and compares them with
174 control group patients with no pancreaticobiliary
Received July 10th, 2009 - Accepted October 27th, 2009
Key words Bile Ducts; Calculi; Cholangiopancreatography,
Endoscopic Retrograde; Pancreatitis; Pancreatitis, Chronic
Abbreviations AICP: alcohol-induced chronic pancreatitis; B-P:
biliary pancreatic union; ERCP: endoscopic retrograde
cholangiopancreatography; P-B: pancreatic biliary union; PBDU:
pancreaticobiliary ductal union; TCP: tropical calcific pancreatitis
Correspondence Mohammad S Khuroo
Digestive Diseases Centre, Dr. Khuroo’s Medical Clinic, Sector 1,
Sher-e-Kashmir Colony, Qamarwari, Srinagar, Kashmir, India
Phone: +91-194.249.0442; Fax: +91-194.249.1190
Document URL

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JOP. J Pancreas (Online) 2010 Jan 8; 11(1):18-24.
JOP. Journal of the Pancreas - - Vol. 11, No. 1 - January 2010. [ISSN 1590-8577]
disease and 35 patients with alcohol-induced chronic
The study included all endoscopic retrograde
cholangiopancreatographies (ERCPs) carried out by the
senior investigator (Author 2) from November 1982 to
March 1995 and from April 2005 to March 2008 in
Kashmir India. All patients belonged to one ethnic
group (residents of Kashmir Valley). All ERCP images
were photographed and compiled into folders, each
folder containing the images of one patient and
carrying a specific patient identification number. The
clinical details, laboratory data, histological findings,
follow-up and diagnosis of patients in whom ERCPs
were carried out were contained in each folder.
For this study, the ERCPs were examined by two
investigators (Authors 1 and 2) independently who
were blinded to the clinical data. The ERCPs were
reviewed from June 2007 to August 2008. The purpose
of the study was to define the patterns of
pancreaticobiliary ductal union in each ERCP. The
findings were recorded on a computer generated
proforma. The method of defining the various features
of pancreaticobiliary ductal union was first mutually
agreed upon [15, 21] and was then practiced on 2

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