Groove Pancreatitis

Antonio Manzelli, Athanasios Petrou, Alesandra Lazzaro,
Nicholas Brennan, Zahir Soonawalla, Peter Friend
Department of Hepatobiliary Surgery, Surgery and Diagnostics Centre, Churchill Hospital.
Headington, Oxford, United Kingdom
ABSTRACT
Context Groove pancreatitis is a rare condition characterized by fibrotic inflammation affecting the groove anatomical area between
the head of the pancreas, the duodenum and the common bile duct. Objectives We report a miniseries of five cases treated surgically
in our centre over a period of four years. A review of the literature is also discussed. Methods Patients undergoing
pancreaticoduodenectomy over a four-year period were retrospectively reviewed. Patients with a confirmed histological diagnosis of
groove pancreatitis were assessed under the headings; patient demographics, presenting symptoms, radiological and histological
findings. Results One-hundred and 60 pancreaticoduodenectomies were performed. Thirty-nine cases demonstrated benign disease
and within this, five cases (3.1% of total series; 12.8% of benign cases) were groove pancreatitis. All patients presented with
abdominal pain and weight loss, and the majority consumed excess alcohol and were smokers. Radiological findings
(CT/MRCP/EUS) revealed duodenal wall thickening in all cases, abnormalities at the head of pancreas and bile duct dilation in four,
and cystic changes in the duodenal wall and pancreatic duct dilation in three cases. Groove fibrosis, Brunner’s gland hyperplasia and
cystic changes in duodenal wall were present in all cases on histological review. All patients reported significant improvement in
quality of life at 12 months after surgery. Conclusion Groove pancreatitis can present in a similar fashion to head of pancreas cancer
and chronic pancreatitis. For this reason it is paramount for clinicians to be aware of groove pancreatitis, as this can lead to the
correct diagnosis and management of this unique disease.
INTRODUCTION
Groove pancreatitis is a rare condition consisting of a
segmental chronic pancreatitis affecting the pancreato-
duodenal groove which is described as a potential
space bordered by the head of the pancreas, duodenum,
and common bile duct [1, 2, 3, 4]. Groove pancreatitis
presents more frequently in males, in their fourth and
fifth decade, with moderate or severe alcohol history
and with symptoms of chronic postprandial epigastric
pain, nausea, vomiting and significant weight loss.
Differentiating on clinical and radiological grounds
between groove pancreatitis and peripancreatic head
cancers can be extremely challenging. The
pathogenesis of groove pancreatitis remains
controversial and unclear despite increased exposure in
the literature. Current theories centre on pancreatic
outflow obstruction at the Santorini duct but several
other factors may be important: peptic ulcers, gastric
resection, true duodenal-wall cysts, and pancreatic
heterotopia in the duodenal wall [3, 4]. We report a
miniseries of five cases treated surgically in our centre
over a period of four years.
MATERIALS AND METHODS
Patients undergoing pancreaticoduodenectomy over a
four-year period (June 2006 to June 2010) at a large
tertiary centre for hepatobiliary and pancreatic surgery
in Oxford, United Kingdom were retrospectively
reviewed. The indications for surgery included
suspected carcinoma of the head of pancreas, chronic
pancreatitis and carcinoma of the ampulla of Vater. All
patients were extensively investigated (CT, MRI,
ERCP, MRCP or EUS) before surgical intervention
was deemed necessary. In all five cases groove
pancreatitis was part of the differential diagnosis based
on radiological findings alone and in all cases was
confirmed by histological analysis. The key
pathological criteria for diagnosis included: 1) dilated
ducts and pseudocystic changes in the duodenal wall;
2) Brunner’s gland hyperplasia; 3) fibrosis in the
adjacent pancreas and soft tissue, especially in the
“groove” area.
Received January 20th, 2011 - Accepted February 11th, 2011
Key words Pancreatic Neoplasms; Pancreatitis; Pancreatitis,
Chronic
Correspondence Nicholas Brennan
16 Ashlawn, Ballinteer Road; Dublin 16; Ireland
Phone: +353-1.296.0006; +44-785.224.7928
Fax: +353-1.296.0006
E-mail: nicky_brennan@hotmail.com
Document URL http://www.joplink.net/prev/201105/02.html

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Patients with a confirmed histological diagnosis of
groove pancreatitis were assessed under the headings
patient demographics, presenting symptoms,
radiological and histological findings (Table 1). At six-
and twelve-month follow a 12-item Short Form Health
Survey (SF-12) was used to assess quality of life.
RESULTS
There were 160 pancreaticoduodenectomies performed
over a four-year period. Thirty-nine cases (24.4%)
revealed benign pancreatic disease and five cases
(3.1% of total series; 12.8% of benign cases)
demonstrated groove pancreatitis. There were three
females and two males with a mean age of 54 years
with a range between 39 and 70 years. All patients with
groove pancreatitis presented with persistent abdominal
pain and weight loss. The majority of these patients
(four) consumed excess alcohol (defined as more than
30 unit/week) and were smokers. Exocrine pancreatic
deficiency and weight loss were noted in all patients
and steatorrhea in three cases. One patient was diabetic
and another presented with jaundice.
All five patients underwent an initial abdominal CT
scan. Three patients had subsequent imaging with
MRCP or EUS and one patient had both. In all cases
duodenal wall thickening was present. Four patients
showed changes at the pancreatic head, either an ill-
defined mass or a swollen head of pancreas (Figure 1).
Bile duct dilation was noted in four of the five cases.
MRI and EUS observations correlated well with CT
findings providing additional information in all cases:
pancreatic duct dilation, duodenal wall thickening and
bile duct dilation.
On histological review, all five cases showed signs of
chronic inflammation with fibrotic changes at the
anatomical groove area between the head of the
pancreas, the duodenum and the common bile duct.
Two cases also demonstrated inflammatory changes at
the head of the pancreas in keeping with segmental
groove pancreatitis with the remaining three labeled
pure groove pancreatitis. Cystic changes in the
duodenal wall were present in all cases (Table 2).
These cysts were embedded in the smooth muscle or
fibrous tissue. The quantity of cysts varied from one to
six and the size ranged from 0.3 to 2.1 cm. Groove
fibrosis and Brunner’s gland hyperplasia were also
demonstrated in all cases. In three cases clusters of
ectopic pancreatic lobules were reported. In these
instances, pancreatic acini and ducts were noted in the
muscle layer, and submucosa of the duodenal wall
adjacent to the ampulla.
After consideration of the available assessment tools
the 12-item Short Form Health Survey (SF-12) was
used to assess quality of life. All five patients reported
cessation or reduction in analgesia, weight gain and
significant improvement in preoperative symptoms and
overall quality of life at 12 months after surgery.
DISCUSSION
The first description resembling groove pancreatitis
was by Potet and Duclert in 1970 as cystic dystrophy
of the pancreas [5] and later in the German literature by
Becker in 1973 as ‘‘segmentare pankreatitis’’[6]. Stolte
et al. later identified the features of groove pancreatitis
in 30 histological specimens obtained from 123
pancreaticoduodenectomies [1]. Stolte et al. defined
‘‘groove pancreatitis’’ as a special form of segmental
pancreatitis characterized by fibrous scars of the
anatomic space between the dorsocranial part of the
head of the pancreas, the duodenum, and the common
bile duct [1]. Becker and Mischke recognized different
types of groove pancreatitis: a “pure” form were only
the anatomical groove was involved; a “segmental”
form in which the scarring affects the dorsocranial
portion of the pancreatic head; and a “non-segmental”
form with a chronic homogenous pancreatitis in
addition to groove involvement [7]. More recently
Adsay and Zamboni have grouped groove pancreatitis,
with cystic dystrophy of the pancreas, pancreatic
hamartoma of duodenum, paraduodenal wall cyst and
myoadenomatosis, and propose a universal name
referred to as “paraduodenal pancreatitis” [8].
Table 1. Patient demographics and primary symptoms during course of groove pancreatitis.
Case
Age (years) Gender
Symptoms
Diabetes
Excess alcohol
Smoker
#1
39
Male
Abdominal pain, weight loss, steatorrhea
No
Yes
Yes
#2
50
Female
Abdominal pain, weight loss, nausea
No
Yes
Yes
#3
54
Female
Abdominal pain, weight loss, nausea
No
Yes
Yes
#4
60
Female
Abdominal pain, weight loss, steatorrhea
Yes
No
No
#5
70
Male
Abdominal pain, weight loss, steatorrhea
No
Yes
Yes
Excess alcohol defined as more than 30 unit/week
Figure 1. Contrast enhanced CT scan demonstrating an ill-defined
hypoechoic mass in the head of the pancreas.

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Despite increased exposure in the literature, the
reported prevalence varies greatly with rates varying
from 2.7%, 19.5%, and 24.5% in three large series of
pancreaticoduodenectomies for chronic pancreatitis [1,
2, 3, 9]. In our series the rate was 3.1%. Patients most
frequently present in their fourth and fifth decade, with
symptoms of long stand postprandial epigastric pain,
radiating to the back, associated with nausea, vomiting
and weight loss. Blood tests often show deranged
pancreatic enzymes and occasionally abnormal liver
function tests without clinical evidence of jaundice [4].
Differentiating groove pancreatitis and peripancreatic
head cancers or more specifically adenocarcinoma of
the head of the pancreas remains a diagnostic
challenge. Typically abdominal ultrasound shows a
hypoechoic mass whereas CT scans often reveal a
hypodense, poorly enhanced mass between the head of
the pancreas and the thickened duodenal wall [10].
Additional imaging with MRCP, EUS and/or ERCP is
essential in further differentiating groove pancreatitis
from head of pancreas cancers [10, 11, 12, 13]. MRI
shows soft-tissue-attenuation images with delayed
enhancement reflecting the fibrous nature noted
between the pancreatic head and the adjacent
duodenum. Irie et al. describes a plate like mass in the
pancreatoduodenal groove that was hypointense
relative to the pancreatic parenchyma on T1-weighted
MRI images and isointense or slightly hyperintense on
T2-weighted MRI [3]. EUS and ERCP often reveal
smooth tubular stenosis of the common bile duct and
irregularity and dilatation of the main pancreatic duct
and its branches. Obstructive jaundice is rarely found
in groove pancreatitis unlike adenocarcinoma of the
head of the pancreas or distal common bile duct.
Having an experienced operator performing the EUS,
CT and MRI cannot be overstated. Overall, the most
well characterized radiological findings are cystic
lesions in the duodenal wall, duodenal wall thickening
and a poorly enhanced mass between the head of the
pancreas and the thickened duodenal wall [8, 13, 14].
In our series this was demonstrated in all five patients.
The pathogenesis of groove pancreatitis remains poorly
defined with disturbances of pancreatic outflow
through the Santorini duct (minor papilla) the most
well established. Here it is postulated that chronic
alcohol intake and/or smoking increases the viscosity
of the pancreatic juice leading to pancreatic duct
calcification and subsequent outflow obstruction of the
pancreatic juices [3, 4]. Hyperplasia of the Brunner’s
glands, possibly secondary to increased cholecysto-
kinin-pancreozymin or gastrin levels may also lead to
stasis of pancreatic juices in the dorsal pancreas and
result in pancreatitis at the anatomical groove [3, 4].
Other factors such as fibrous scarring secondary to
peptic ulcers, gastric and duodenal resections or true
duodenal-wall cysts may also be related [3].
In many instances resection is often performed as the
diagnosis of groove pancreatitis is unclear. However,
with an increased understanding in the radiological
findings, initial non-surgical treatments are more
frequently employed. These conservative options
involve cessation of smoking and alcohol, adequate
analgesia, resting the pancreas and in some instances
endoscopic stenting of the minor papilla. However,
these measures are only temporary and surgery is
inevitable when symptoms fail to improve or, in many
cases, when there is uncertainty over the diagnosis.
Pancreaticoduodenectomy or pylorus-preserving
pancreaticoduodenectomy offer a curative treatment for
groove pancreatitis with complete resolution of
symptoms in most cases [1]. Histopathological
assessment of the resected specimen reveals
characteristic fibrous scarring and thickening of the
duodenal wall between the duodenal lumen and the
pancreas.
The macro- and microscopic features of groove
pancreatitis are quite similar to those reported for
cystic dystrophy of the duodenal wall [1, 2, 3, 4].
Cystic dystrophy of the duodenal wall, an entity that is
most likely related to groove pancreatitis, is
Table 2. Radiological and histopathological findings.
Case
CT
MRCP
EUS
Histology
#1
Duodenal wall thickening, chronic
pancreatitis, cystic changes
duodenal wall
Cystic changes duodenal wall,
duodenal wall thickening,
pancreatic duct dilation, biliary
duct dilation
Not done
Cystic changes duodenal wall,
groove fibrosis, Brunner’s gland
hyperplasia, ectopic pancreatic
tissue, pancreatic duct dilation
#2
Duodenal wall thickening, 3cm
mass head of pancreas, cystic
changes duodenal wall
Not done
Duodenal wall thickening, swollen
head of pancreas, biliary duct
dilation, mass head of pancreas ,
cystic changes duodenal wall
Cystic changes duodenal wall,
groove fibrosis, Brunner’s gland
hyperplasia, biliary duct dilation,
ectopic pancreatic tissue
#3
Duodenal wall thickening, biliary
duct dilation
Biliary duct dilation, pancreatic
duct dilation, duodenal wall
thickening
Not done
Cystic changes duodenal wall,
groove fibrosis, Brunner’s gland
hyperplasia, pancreatic duct
dilation
#4
Cystic mass head of pancreas (3
cm), chronic pancreatitis
Cystic mass head of pancreas (2.5
cm), duodenal wall thickening
Duodenal wall thickening, swollen
head of pancreas, cystic changes
duodenal wall
Cystic changes duodenal wall
groove fibrosis, Brunner’s gland
hyperplasia, ectopic pancreatic
tissue
#5
Duodenal wall thickening, cystic
changes duodenal wall, biliary duct
dilation
Not done
Duodenal wall thickening, cystic
changes duodenal wall, pancreatic
duct dilation, swollen head of
pancreas, biliary duct dilation
Cystic changes duodenal wall,
groove fibrosis, Brunner’s gland
hyperplasia, biliary duct dilation

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characterized by the presence of cystic lesions in the
thickened wall of the second portion of the duodenum.
Other important histopathological findings in groove
pancreatitis include groove fibrosis, Brunner’s gland
hyperplasia and ectopic pancreatic tissue in the
duodenal wall.
CONCLUSION
Groove pancreatitis is a unique disease which can
present with symptoms suggestive of pancreatic cancer.
In our series the diagnosis of groove pancreatitis was
identified in 4 out of 5 cases based on clinical
symptoms and radiological findings alone. The most
important of these findings are cystic lesions in the
duodenal wall, duodenal wall thickening and a poorly
enhanced mass between the head of the pancreas and
the thickened duodenal wall. Pancreaticoduodenectomy
can be curative with complete resolution of symptoms
in many. Overall, it is paramount for clinicians to be
aware of groove pancreatitis, as this can lead to the
correct diagnosis and management of this unique
condition.
Conflict of interest The authors have no potential
conflict of interest
References
1. Stolte M, Weiss W, Volkholz H, Rosch W. A special form of
segmental pancreatitis: groove pancreatitis. Hepatogastroenterology
1982; 29:198-208. [PMID 7173808]
2. Becker V, Bauchspeichel D. Spezielle Pathologische Anatomic
Bd. VI. In: Doerr W, Seifert G, Uhlinger E, Eds. Springer, Berlin-
Heidelberg-New York, 1973.
3. Irie H, Honda H, Kuroiwa T, Hanada K, Yoshimitsu K, Tajima
T, et al. MRI of groove pancreatitis. J Comput Assist Tomogr 1998;
22:651-5. [PMID 9676462]
4. Itoh S, Yamakawa K, Shimamoto K, Endo T, Ishigaki T. CT
findings in groove pancreatitis: correlation with histopathological
findings. J Comput Assist Tomogr 1994; 18:911-5. [PMID 7962798]
5. Potet F, Duclert N. Cystic dystrophy on aberrant pancreas of the
duodenal wall. Arch Fr Mal App Dig 1970; 59:223-38. [PMID
5419209]
6. Becker V. Proceedings: Fundamental morphological aspects of
acute and chronic pancreatitis (author's transl). Langenbecks Arch
Surg 1973; 334:317-22. [PMID 4776105]
7. Becker V, Mischke U. Groove pancreatitis. Int J Pancreatol
1991; 10:173-82. [PMID 1787332]
8. Adsay NV, Zamboni G. Paraduodenal pancreatitis: a clinico-
pathologically distinct entity unifying 'cystic dystrophy of
heterotopic pancreas', 'para-duodenal wall cyst', and 'groove
pancreatitis'. Semin Diagn Pathol 2004; 21:247-54. [PMID
16273943]
9. Yamaguchi K, Tanaka M. Groove pancreatitis masquerading as
pancreatic carcinoma. Am J Surg 1992; 163:312-6. [PMID 1539765]
10. Gabata T, Kadoya M, Terayama N, Sanada J, Kobayashi S,
Matsui O. Groove pancreatic carcinomas: radiological and
pathological findings. Eur Radiol 2003; 13:1679-84. [PMID
12835985]
11. Tio TL, Luiken GJ, Tytgat GN. Endosonography of groove
pancreatitis. Endoscopy 1991; 23:291-3 [PMID 1743134]
12. Rahman SH, Verbeke CS, Gomez D, McMahon MJ, Menon KV.
Pancreatico-duodenectomy for complicated groove pancreatitis. HPB
(Oxford) 2007 ;9:229-34. [PMID 18333228]
13. Fléjou JF, Potet F, Molas G, Bernades P, Amouyal P, Fékété F.
Cystic dystrophy of the gastric and duodenal wall developing in
heterotopic pancreas: an unrecognised entity. Gut 1993; 34:343-7.
[PMID 8097180]
14. Lai EC, Tompkins RK. Heterotopic pancreas. Review of a 26
year experience. Am J Surg 1986; 151:697-700. [PMID 37175

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