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PubMed This is a summary of 20 peer-reviewed journal articles Updated
Gastroenterology

More Than Just a Ring: Associated Conditions and Complications

At a Glance

Annular pancreas frequently occurs alongside other genetic and anatomical variations, such as Down syndrome and intestinal malrotation in infants. In adults, it can cause long-term complications including chronic pancreatitis, peptic ulcers, and biliary obstruction.

Because annular pancreas occurs during a critical window of early development, it often does not occur in isolation. It can be thought of as one “glitch” in a series of events that may have affected other parts of the body as well [1][2]. Understanding these associations helps doctors provide more comprehensive care and prevent unexpected complications [3][4].

For Neonates: Common Concurrent Anomalies

When a baby is diagnosed with an annular pancreas, doctors immediately look for other structural or genetic variations that are known to “travel” with this condition [1].

  • Chromosomal Variations: There is a well-established link between Down syndrome (Trisomy 21) and congenital duodenal blockages, including annular pancreas [5][6]. Approximately 10% to 30% of infants with duodenal obstruction also have Down syndrome [7].
  • Intestinal Malrotation: This occurs when the intestines do not rotate and “settle” into the correct spot in the abdomen [3]. This is a critical finding because it can lead to a twisted bowel (volvulus), which is a separate surgical emergency [3].
  • Preduodenal Portal Vein (PDPV): In some cases, a major vein (the portal vein) that usually sits behind the duodenum instead grows in front of it [8]. This is an vital finding for surgeons to know before operation, as it requires very careful handling to avoid bleeding [9][10].
  • VACTERL Association: Rarely, annular pancreas is part of a cluster of anomalies affecting the Vertebrae, Anus, Cardiac (heart), Trachea, Esophagus, Renal (kidneys), and Limbs [11][12].

For Adults: The Toll of Time

In adults, the “associated conditions” are often complications caused by the pancreatic ring being undiagnosed for years [13].

  • Chronic Pancreatitis: Because the unusual shape of the pancreas can “pinch” the drainage ducts, digestive juices can get backed up, leading to repeated inflammation [14]. Over time, this can cause permanent scarring of the organ [15].
  • Peptic Ulcer Disease: The blockage in the duodenum can cause stomach acid to pool and sit in one place longer than it should, leading to the development of painful ulcers or even gastric outlet obstruction (where the stomach cannot empty at all) [13][16].
  • Biliary Obstruction: If the ring is high enough, it can squeeze the bile duct, leading to jaundice (yellowing of the skin) or stones in the bile duct [17].

The “Double Trouble”: Pancreas Divisum

As discussed in the biology section, nearly 45.7% of patients with an annular pancreas also have pancreas divisum [18]. In this condition, the two main drainage ducts of the pancreas fail to fuse [15].

  • Why it matters: This configuration increases the pressure inside the pancreatic ducts because they are too small to handle the volume of digestive fluid [19]. When combined with the “squeeze” of an annular ring, it significantly increases the risk of recurrent, painful pancreatitis [19][18].

Screening and Safety

To ensure no surprises during treatment, current medical standards involve a “whole-body” look at the patient. This includes echocardiograms to check the heart, ultrasounds of the kidneys, and high-definition CT or MRI scans to map out every vein and duct before any surgery begins [20][9][3]. Knowing the full “map” of your or your child’s anatomy is the best way to ensure a safe and successful recovery [4].

Common questions in this guide

What other health conditions are common in babies with an annular pancreas?
Babies diagnosed with an annular pancreas often have other structural or genetic variations. The most common associations include Down syndrome (Trisomy 21), intestinal malrotation, and an unusual placement of the portal vein.
Can an undiagnosed annular pancreas cause problems later in life for adults?
Yes, adults who have lived with an undiagnosed annular pancreas for years frequently develop complications. The unusual shape of the pancreas can cause long-term damage, leading to chronic pancreatitis, peptic ulcer disease, or bile duct blockages.
What is pancreas divisum and how does it relate to an annular pancreas?
Pancreas divisum is an anatomical variation where the main drainage ducts of the pancreas fail to fuse properly. Nearly half of patients with an annular pancreas also have pancreas divisum, which significantly increases the risk of experiencing recurrent, painful pancreatitis.
Why do doctors order heart and kidney tests before annular pancreas surgery?
Doctors recommend a 'whole-body' look because an annular pancreas is rarely an isolated issue. Imaging tools like echocardiograms, ultrasounds, and CT scans allow the surgical team to map out all veins, ducts, and organs to avoid unexpected complications during surgery.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.Have you screened my child for other 'midline' anomalies, such as cardiac defects or kidney issues?
  2. 2.Does the imaging show 'Ladd's bands' or any other signs of intestinal malrotation that should be fixed during the same surgery?
  3. 3.Is there a 'preduodenal portal vein' present? If so, how does that change your surgical plan to ensure safety?
  4. 4.In my case, do I have pancreas divisum, and how does that affect my risk for future bouts of pancreatitis?
  5. 5.Since I have chronic pain, are there signs of old scarring or peptic ulcers that need to be addressed along with the bypass?

Questions For You

Tap a prompt to share your answer — we'll use it plus this page's context to start a tailored conversation.

References

References (20)
  1. 1

    Annular pancreas in neonates; Case series and review of literatures.

    Ali Almoamin HH, Kadhem SH, Saleh AM

    African journal of paediatric surgery : AJPS 2022; (19(2)):97-101 doi:10.4103/ajps.AJPS_180_20.

    PMID: 35017379
  2. 2

    Exome sequencing findings in children with annular pancreas.

    Pitsava G, Pankratz N, Lane J, et al.

    Molecular genetics & genomic medicine 2023; (11(10)):e2233 doi:10.1002/mgg3.2233.

    PMID: 37635636
  3. 3

    The diagnostic accuracy of ultrasound and upper gastrointestinal contrast studies for locating atresia/stenosis and intestinal malrotation and detecting annular pancreas in pediatric patients with duodenal atresia/stenosis.

    Hosokawa T, Tanami Y, Sato Y, et al.

    Journal of medical ultrasonics (2001) 2022; (49(2)):299-309 doi:10.1007/s10396-021-01176-1.

    PMID: 34988762
  4. 4

    Multiseptate gallbladder accompanied by an incomplete annular pancreas in a 19-year male patient: A case report.

    Nikolovski A, Misimi S, Trpeski S, Atanasov Z

    Radiology case reports 2025; (20(10)):5042-5045 doi:10.1016/j.radcr.2025.06.058.

    PMID: 40727894
  5. 5

    Annular pancreas as a cause of neonatal duodenal obstruction, a case report.

    Gutiérrez-González JA, González De La Torre E, Armijo-Borjón EA, et al.

    Journal of surgical case reports 2023; (2023(7)):rjad407 doi:10.1093/jscr/rjad407.

    PMID: 37489161
  6. 6

    Atypical Presentation of Duodenal Atresia in a Newborn With Trisomy 21: A Simulated Case Report and Narrative Review.

    Tam CW, Patel S, Massoumi J, et al.

    Pediatric annals 2025; (54(4)):e139-e143 doi:10.3928/19382359-20250206-04.

    PMID: 40163714
  7. 7

    Congenital Duodenal Obstruction in Neonates: Over 13 Years' Experience from a Single Centre.

    Kumar P, Kumar C, Pandey PR, Sarin YK

    Journal of neonatal surgery 2016; (5(4)):50 doi:10.21699/jns.v5i4.461.

    PMID: 27896158
  8. 8

    [A Case of Distal Bile Duct Cancer Associated with Preduodenal Portal Vein].

    Suzuki S, Aono T, Maruyama T, et al.

    Gan to kagaku ryoho. Cancer & chemotherapy 2024; (51(13)):1378-1380.

    PMID: 39948862
  9. 9

    [A Case of Cholangiocarcinoma with Intestinal Malrotation Treated with Pancreaticoduodenectomy].

    Saito Y, Miyamoto A, Maeda S, et al.

    Gan to kagaku ryoho. Cancer & chemotherapy 2015; (42(12)):1729-31.

    PMID: 26805153
  10. 10

    Prepancreatic postduodenal portal vein: a case report and review of the literature.

    Goussous N, Cunningham SC

    Journal of medical case reports 2017; (11(1)):2 doi:10.1186/s13256-016-1165-3.

    PMID: 28049511
  11. 11

    VACTERL syndrome with late presentation of annular pancreas with duodenal web: Case report.

    Yoon Y, Dragusin IB, Gallagher ME, Clark P

    Radiology case reports 2022; (17(6)):1853-1857 doi:10.1016/j.radcr.2022.02.062.

    PMID: 35401909
  12. 12

    Annular Pancreas, Severe Tracheomalacia and Bronchomalacia in a Preterm Boy with Vacterl Association.

    Akdag A, Turgut A, Ceylan S, Kaya M

    Genetic counseling (Geneva, Switzerland) 2016; (27(2)):207-10.

    PMID: 29485824
  13. 13

    From duodenitis to stricture: Decoding the impact of partial annular pancreas over years.

    Alok H, Bansal L, Prasad A

    Abdominal radiology (New York) 2026; (51(4)):1765-1769 doi:10.1007/s00261-025-05194-2.

    PMID: 41369896
  14. 14

    Annular pancreas causing pyloric stenosis in a 66-year-old patient treated with gastrojejunostomy: a case report.

    Patel P, Diko S, Kulkarni S, et al.

    Journal of surgical case reports 2021; (2021(4)):rjab125 doi:10.1093/jscr/rjab125.

    PMID: 33927863
  15. 15

    Rendezvous-assisted endoscopic retrograde pancreatography in a patient with annular pancreas and coexisting pancreas divisum.

    Zhai Y, Li M, Li H, et al.

    Endoscopy 2023; (55(S 01)):E559-E560 doi:10.1055/a-2032-3462.

    PMID: 36958350
  16. 16

    Annular Pancreas: A Rare Cause of Upper Gastrointestinal Bleeding in Adults.

    Kweun JA, Kang HM, Kim JE, Park SJ

    The Korean journal of gastroenterology = Taehan Sohwagi Hakhoe chi 2022; (79(4)):182-186 doi:10.4166/kjg.2022.012.

    PMID: 35473777
  17. 17

    Cholangitis secondary to obstructive choledocholithiases in an elderly woman with heterotaxy syndrome with polysplenia: report of a case and brief review of the literature.

    Láinez Ramos-Bossini AJ, Córdoba-Peláez P, Redruello-Guerrero P

    Clinical journal of gastroenterology 2022; (15(2)):401-406 doi:10.1007/s12328-021-01574-5.

    PMID: 35066797
  18. 18

    Annular pancreas: endoscopic and pancreatographic findings from a tertiary referral ERCP center.

    Gromski MA, Lehman GA, Zyromski NJ, et al.

    Gastrointestinal endoscopy 2019; (89(2)):322-328 doi:10.1016/j.gie.2018.09.008.

    PMID: 30240880
  19. 19

    Pancreatic Divisum Causing Recurrent Pancreatitis in an 8-Year-Old Child.

    Tiwari C, Basu S, Makan A, Shah H

    Journal of Indian Association of Pediatric Surgeons 2022; (27(5)):655-656 doi:10.4103/jiaps.jiaps_249_21.

    PMID: 36530823
  20. 20

    Multiple associated anomalies in patients of duodenal atresia: a case series.

    Mirza B, Sheikh A

    Journal of neonatal surgery 2012; (1(2)):23.

    PMID: 26023382

This page explains conditions and complications associated with annular pancreas for educational purposes only. Always consult your gastroenterologist or pediatric surgeon for an evaluation of your specific anatomy and medical history.

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