What is Groove Pancreatitis (Pancreatitis)?
Groove pancreatitis is a rare type of inflammation that affects both the duodenum, which is part of the small intestine, and the pancreas. Specifically, this inflammation occurs in the space between the head of the pancreas, the inner wall of the second part of the duodenum, and the common bile duct.
The condition was first mentioned in 1970 by French authors, Potet and Duclert, who used the term ‘cystic dystrophy of the heterotopic pancreas.’ Later, a German physician, Becker, introduced the term ‘Rinnenpankreatitis’ in 1973. The phrase ‘groove pancreatitis’ was put forward by Stole et al. in 1982, and since then, it has been used to refer to similar conditions like para-duodenal pancreatitis, cystic dystrophy of the heterotopic pancreas, periampullary duodenal wall cyst, and pancreatic hamartoma of the duodenum.
The cause of groove pancreatitis is related to fibrosis or scarring that occurs in the area around the duodenum and the pancreas. This can disrupt the normal secretions of the pancreas, leading to inflammation. Stole and his team identified two types of groove pancreatitis: pure and segmental. In the pure form, the inflammation only affects the groove area. On the other hand, segmental groove pancreatitis involves inflammation that not only affects the groove area but also extensively spreads into the head of the pancreas.
What Causes Groove Pancreatitis (Pancreatitis)?
Drinking alcohol excessively can significantly increase the risk of developing a certain type of inflammation of the pancreas known as groove pancreatitis. Regular heavy drinking can cause two main problems in the pancreas. Firstly, it reduces the size of the pancreas, and secondly, it thickens the juices that the pancreas produces.
Alcohol consumption can also lower the concentration of a compound called citrate in the pancreas juices. This can cause those juices to crystallize in the primary tube, or duct, of the pancreas known as the “duct of Wirsung”, acting as a starting point for stone formation in the pancreas. Alcohol consumption can also lead to an overgrowth of Brunner’s glands, which are glands found in the second part of the small intestine called the duodenum.
Additionally, stones created within the pancreatic ducts can block a smaller duct known as the “Santorini duct” where it connects to the minor papilla, a small bump-like part in the duodenum. Chronic alcoholics can also develop protein-filled blockages in the pancreatic ducts that are not yet fully formed stones.
Certain physical abnormalities or functional issues can alter the secretions of the pancreas. These abnormal conditions might include a divided pancreas “pancreatic divisum”, a ring-shaped pancreas “annular pancreas”, and misplaced pancreas “ectopic pancreas”. Functional issues could include thickening of the duodenal wall.
Interestingly, stomach ulcers have also been suggested by some researchers as a possible cause of groove pancreatitis. Other factors include sections of the stomach, cysts in the head of the pancreas, and previous problems with the bile ducts.
Risk Factors and Frequency for Groove Pancreatitis (Pancreatitis)
Groove pancreatitis, a condition that affects the pancreas, is seen in around 8.9% of patients in its pure form and in approximately 15.5% of patients in its segmental form, according to a study involving 123 patients. It’s relevant to note that this condition has been linked to alcohol use disorder. It is more commonly found in males who are in their fifties. While females can also have groove pancreatitis, it’s less prevalent among them.
- Groove pancreatitis appears in different forms: in 8.9% of cases, it’s the pure form; in 15.5% of cases, it’s the segmental form.
- This condition is associated with alcohol use disorder.
- It is most commonly seen in men in their fifties.
- While groove pancreatitis can occur in women, it is less frequent.
Signs and Symptoms of Groove Pancreatitis (Pancreatitis)
People who suffer from a specific type of inflammation of the digestive system often experience symptoms such as abdominal pain, particularly in the upper part of the belly, weight loss, vomiting after meals, and diarrhea. If this inflammation impacts the duct that carries bile from the liver to the gallbladder, jaundice, or yellowing of skin and whites of the eyes may occur.
A study by Kager and colleagues involving 335 patients found the following symptoms:
- Abdominal pain in 92% of the patients (308 out of 335 people)
- Vomiting in 31% of the patients (105 out of 335 people)
- Weight loss in 78% of the patients (215 out of 277 people)
- Jaundice in 12% of the patients (32 out of 261 people)
- Cholestasis, a condition where bile cannot flow from the liver to the gallbladder, in 28% of the patients (73 out of 264 people)
- Steatorrhea, which is excessive fat in stools, in 27% of the patients (48 out of 179 people)
Testing for Groove Pancreatitis (Pancreatitis)
In order to understand if a patient has a certain type of pancreatitis, doctors use various laboratory tests. Commonly used markers such as pancreatic enzymes like lipase, amylase, and elastase might increase a little bit. Liver enzymes can also be slightly raised. Alkaline phosphatase and GGT, markers of bile flow, may also show a mild increase. Bilirubin, another substance involved in digestion, can be slightly high in patients with bile duct issues. Unlike in the cases of pancreatic cancer, tumor markers like carcinoembryonic antigen (CEA), and carbohydrate antigen (CA-19-9) are typically normal.
Imaging can provide more insights about the patient’s condition. For example, ultrasound can reveal a very reflective mass along with thickening of the duodenal wall, a part of the small intestine. The ultrasound findings depend on the evolution stage of the pancreatitis, being more prominent in the early stages and reducing as the disease progresses and causes fibrosis, or tissue thickening.
A CT scan can show a dense abnormal tissue mass and might also reveal various-sized cysts in the duodenum or a multilocular cystic mass. The main pancreatic duct usually appears normal.
An ERCP (Endoscopic retrograde cholangiopancreatography) procedure can reveal narrowing of the bile duct and some changes on the pancreatic duct. However, this procedure can be challenging to perform due to the narrowing of the duodenum. Ultrasound Endoscopy can be helpful to determine the exact location of the disease and other findings such as duodenal stenosis, common bile duct stricture, and cysts in the duodenal wall.
EUS (Endoscopic Ultrasound) with a biopsy might show cells that indicate inflammation, but this doesn’t automatically mean cancer.
MRI (Magnetic Resonance Imaging) is considered the best diagnostic method. It shows the presence of a sheet-like mass between the duodenum and the pancreas. This mass appears different than the pancreatic tissue on T1 and T2 weighted images. More pronounced thickening and narrowing of the duodenal wall can also be seen. In the segmental form, the whole pancreas is seen as less intense on T1 weighted imaging along with pancreatic thinning and ductal dilation due to loss of cellular parts and replacement with fibrotic tissue. However, distinguishing between groove pancreatitis and pancreatic head cancer can be challenging because both conditions cause a lot of scarring and fibrosis. Certain features observed during a CT or MRI might help tell these two conditions apart.
If certain criteria are met according to a study done by Kalb et al., the chance of diagnosing groove pancreatitis using MRI can be high, up to 87.2%. If three specific criteria are found – thickening of the second part of the duodenum, abnormally raised enhancement of the second part of the duodenum, and cystic changes in the area of the dorsal pancreatic duct – the chance of ruling out pancreatic head carcinoma is 92.9%.
Treatment Options for Groove Pancreatitis (Pancreatitis)
There are several ways to manage groove pancreatitis. The options range from conservative treatments such as lifestyle changes, to endoscopic procedures and surgery.
Firstly, conservative management suggests maintaining a balanced diet, using pain medications, resting the pancreas and not consuming alcohol or smoking. This approach might bring immediate relief, but the effects tend not to last long. Certain drugs like octreotide could be useful as well. When it’s difficult for a patient to take in nutrition through normal eating due to blockages, they might need to be given nutrients directly into their blood vessels.
Next, endoscopic treatments are available. These involve using a tube with a camera to access the digestive system and carry out procedures like widening narrowed areas and draining any excess fluid or pseudocysts. These procedures work best in the early stages of the disease; as the disease progresses and more scarring takes place, these methods become less effective. There have been reports of placing a stent in a duct to help pancreatic fluids drain more easily and reduce pain. However, cases of poor results and complications, such as the stent moving or becoming blocked, have been noted.
Finally, surgery is often the go-to option for patients who don’t respond to simpler methods, or for whom there is a suspicion of a cancerous growth. The Whipple’s procedure, which involves removing a part of the pancreas, is typically chosen. This surgery has been reported to effectively relieve pain and restore weight loss in most patients. A slightly modified version of a Whipple procedure can sometimes be performed, which preserves parts of the digestive system. However, due to excessive scarring, this might not always be possible. In patients who have substantial narrowing in their digestive tract or are not candidates for pancreas removal, a surgical procedure that involves removing a part of the small intestine while keeping the pancreas may be used.
What else can Groove Pancreatitis (Pancreatitis) be?
- Pancreatic cancer (specifically, adenocarcinoma)
- Cancer in the small intestine (duodenal adenocarcinoma)
- Cancers around the area where the bile duct and pancreas connect to the small intestine (periampullary cancers)
- A type of tumor in the pancreatic groove that originates from cells creating hormones (pancreatic groove neuroendocrine tumor)
- A condition that results in cysts forming in the small intestine (cystic dystrophy of the duodenum)
- Pancreatitis accompanied with swelling (conventional edematous pancreatitis) which also affects the groove
- Sudden inflammation of the pancreas (acute pancreatitis)
changes.
What to expect with Groove Pancreatitis (Pancreatitis)
Typically, treatment starts with a non-invasive approach, incorporating medication and endoscopic therapy during the early stages. Suggested non-invasive management includes maintaining a healthy balanced diet, managing pain, resting the pancreas, and avoiding alcohol and smoking. These methods often provide short-term relief, and in some cases, they may even offer long-term benefits.
While endoscopic therapies can be helpful, they may not be successful in 10 to 20% of patients. For those whose condition does not improve with non-invasive methods or when a diagnosis is unclear, surgery becomes the preferred treatment. In most of these cases, a particular type of surgery known as a Whipple pancreaticoduodenectomy is performed.
Possible Complications When Diagnosed with Groove Pancreatitis (Pancreatitis)
Some complications can derive from the inflammation caused by groove pancreatitis, a condition that affects your pancreas. The issues that can happen include bleeding in your digestive system, stomach perforation leading to inflammation of the stomach lining, ongoing severe abdominal pain, narrowing of the beginning parts of your small intestine, blockage in the bile duct, chronic inflammation of the pancreas, and even the possibility of your pancreas turning cancerous.
Here’s a simple breakdown of these potential complications:
- Bleeding in your digestive system
- Perforation leading to stomach lining inflammation
- Ongoing severe abdominal pain
- Narrowing of the beginning parts of your small intestine
- Blockage in the bile duct
- Inflammation of the pancreas over a long period
- Possibility of pancreatic cancer
Preventing Groove Pancreatitis (Pancreatitis)
It’s important that all patients are informed about the signs and symptoms of groove pancreatitis. They should understand that symptoms can include pain in the upper part of the stomach, weight loss, vomiting after eating due to a narrow duodenum (part of the small intestine), and diarrhea. They should be advised to stop drinking alcohol, to monitor their weight, and to contact their doctor if they experience any stomach pain and vomiting alongside these symptoms.
Patients should be specifically taught to look out for serious symptoms like jaundice (yellowing of the skin or eyes), difficulty eating or drinking, and a decrease in appetite. It’s also important to make sure that patients are familiar with the different treatment options available, like medicine, endoscopy (a procedure that uses a flexible tube to look inside the digestive tract), and surgery. They should have a clear grasp of the risks, benefits, and alternatives of each treatment approach.
