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DOI:10.2214/AJR.06.1244
AJR 2007; 189:73-80
© American Roentgen Ray Society

Pictorial Essay

MRI Features of Groove Pancreatitis

Roberto Blasbalg1, Ronaldo Hueb Baroni1, Daniel Nobrega Costa1,2 and Marcel Cerqueira Cesar Machado3

1 Department of Radiology, Hospital das Clinicas, Universidade de São Paulo, São Paulo, Brazil.
2 Present address: Department of Radiology, Beth Israel Deaconess Medical Center and Harvard Medical School, 170 Brookline Ave., Unit 911, Boston, MA 02215-3924.
3 Department of Gastrointestinal Surgery, Hospital das Clinicas, Universidade de São Paulo, São Paulo, Brazil.

Received September 20, 2006; accepted after revision January 17, 2007.

 
Address correspondence to D. N. Costa (dnobrega{at}gmail.com).


Abstract
Top
 Abstract
Introduction
 MRI Findings of Groove...
 Conclusion
 References
 
OBJECTIVE. The purpose of this article is to discuss and illustrate the most relevant and unique MRI features of groove pancreatitis.

CONCLUSION. Groove pancreatitis in an uncommon type of focal chronic pancreatitis. Its appearance may resemble pancreatic adenocarcinoma. Although distinction between these two entities remains challenging, knowledge of MRI findings is important in suggesting the correct diagnosis and programming therapeutic decisions.

Keywords: abdominal imaging • MRI • pancreas • pancreaticobiliary imaging • pancreatitis


Introduction
Top
 Abstract
 Introduction
MRI Findings of Groove...
 Conclusion
 References
 
Groove pancreatitis is an uncommon type of focal chronic pancreatitis affecting the groove between the head of the pancreas, the duodenum, and the common bile duct. The pancreatic parenchyma is spared or slightly compromised [1, 2]. Groove pancreatitis was first described by Becker in 1973 [3], but this condition remains unknown to most clinicians, and only a few case reports have been published.

The clinical setting is similar to the usual form of chronic pancreatitis, but recurrent vomiting, attributable to marked duodenal stenosis and impaired motility, tends to be more pronounced in groove pancreatitis [2, 4]. Jaundice is not usual and, if present, often fluctuates, in contrast to the continuously progressive jaundice found in patients with pancreatic carcinoma [5]. Amylase serum levels may be elevated [4, 6].

The pathogenesis of groove pancreatitis remains controversial. Several factors may be related, including previous diseases of the biliary system, peptic ulcers, gastric resections, true duodenal wall or pancreatic head cysts, and pancreatic head heterotopia in the duodenum [2, 5, 7].

Groove pancreatitis is usually classified into pure and segmental forms [2]. The pure form affects exclusively the groove. The segmental form extends to the pancreatic head despite a clear predominance in the groove [1, 2] (Figs. 1A and 1B). However, we believe that cases with findings of groove pancreatitis as well as signs of diffuse chronic pancreatic disease must be considered as having the groove form of disease, because a pure or segmental form can cause progressive stenosis of the pancreatic duct and subsequently lead to diffuse chronic pancreatitis.


Figure 1
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  		Fig. 1A —Schematic drawings of groove pancreatitis. Drawings depict fibrotic tissue in pancreaticoduodenal groove (pure form, A) that also involves pancreatic head (segmental form, B).

 

Figure 2
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  		Fig. 1B —Schematic drawings of groove pancreatitis. Drawings depict fibrotic tissue in pancreaticoduodenal groove (pure form, A) that also involves pancreatic head (segmental form, B).

 
The histopathologic hallmark of groove pancreatitis is the presence of scar tissue with fibrosis in the pancreaticoduodenal groove or in the groove and the superior portion of the pancreatic head (in the pure and segmental forms of the disease, respectively). The duodenum is always involved by a chronic inflammatory process, with scar tissue in the wall leading to fibrosis and various levels of stenosis. Hyperplasia of Brunner's glands is also a major finding that is seen in almost all cases. Cystic lesions, either true cysts or pseudocysts, are frequently encountered in the groove or the duodenal wall [8]. Although the origin of the cystic changes is controversial, according to most accepted theories they represent cystic dystrophy of a heterotopic pancreas in the duodenal wall [9].

The most relevant differential diagnosis of groove pancreatitis (particularly in its segmental form) is adenocarcinoma of the head of the pancreas. The preoperative distinction between these entities has always been considered challenging. Other differential diagnoses include duodenal cancer and cholangiocarcinoma of the distal common bile duct.

Imaging findings are important in establishing a differential diagnosis and programming therapeutic decisions. The appearance of the disease has been already described on barium studies [4], endoscopic sonography [10], ERCP [4], and CT [6]. However, few articles have described the features of this disease on MRI [1, 11].


MRI Findings of Groove Pancreatitis
Top
 Abstract
 Introduction
 MRI Findings of Groove...
Conclusion
 References
 
Mass in the Pancreaticoduodenal Groove
The most characteristic finding on MRI is a sheetlike mass between the head of pancreas and the C-loop of duodenum. The mass is hypointense to pancreatic parenchyma on T1-weighted images (Figs. 2A and 2B) and can be hypo-, iso-, or slightly hyperintense on T2-weighted images (Fig. 3). This variation in the T2 signal can be attributed to the time of onset of the disease because subacute disease shows brighter T2 images due to edema, and chronic disease has a lower signal due to fibrosis. Contrast-enhanced dynamic images show a delayed and progressive inhomogeneous enhancement that reflects the fibrous nature of the tissue (Figs. 4A, 4B, 4C, 4D, 5A, 5B, 5C, and 5D). Most pancreatic adenocarcinomas are relatively hypovascular and may present a scirrhous character resulting from the presence of dense fibrotic tissue in the mass. Thus, contrast enhancement patterns can be similar in both conditions [11]. Nevertheless, cancer usually has a more round and discrete appearance (Figs. 6A, 6B, and 6C).


Figure 3
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  		Fig. 2A —34-year-old woman and 32-year-old man with groove pancreatitis. Fast spoiled gradient-echo (TR/TE, 150/minimum) T1-weighted images of two patients show hypointense mass in pancreaticoduodenal space (arrows). Pancreatic parenchyma is spared in B, indicating pure form of groove pancreatitis.

 

Figure 4
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  		Fig. 2B —34-year-old woman and 32-year-old man with groove pancreatitis. Fast spoiled gradient-echo (TR/TE, 150/minimum) T1-weighted images of two patients show hypointense mass in pancreaticoduodenal space (arrows). Pancreatic parenchyma is spared in B, indicating pure form of groove pancreatitis.

 

Figure 5
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  		Fig. 3 —31-year-old man with groove pancreatitis. Axial fat-suppressed fast spinecho T2-weighted image with respiratory triggering (TR range/TE, 4,000–6,000/90) reveals duodenal wall thickening and intermediate signal intensity secondary to inflammatory process in pancreaticoduodenal groove (arrow).

 

Figure 6
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  		Fig. 4A —45-year-old man with groove pancreatitis. Unenhanced and dynamic contrast-enhanced axial fast spoiled gradient-echo fat-suppressed T1-weighted images (A, unenhanced; B, arterial phase; C, venous phase; D, equilibrium phase) show progressive enhancement of inflammatory process in pancreaticoduodenal groove (arrows), characteristic of fibrous tissue.

 

Figure 7
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  		Fig. 4B —45-year-old man with groove pancreatitis. Unenhanced and dynamic contrast-enhanced axial fast spoiled gradient-echo fat-suppressed T1-weighted images (A, unenhanced; B, arterial phase; C, venous phase; D, equilibrium phase) show progressive enhancement of inflammatory process in pancreaticoduodenal groove (arrows), characteristic of fibrous tissue.

 

Figure 8
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  		Fig. 4C —45-year-old man with groove pancreatitis. Unenhanced and dynamic contrast-enhanced axial fast spoiled gradient-echo fat-suppressed T1-weighted images (A, unenhanced; B, arterial phase; C, venous phase; D, equilibrium phase) show progressive enhancement of inflammatory process in pancreaticoduodenal groove (arrows), characteristic of fibrous tissue.

 

Figure 9
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  		Fig. 4D —45-year-old man with groove pancreatitis. Unenhanced and dynamic contrast-enhanced axial fast spoiled gradient-echo fat-suppressed T1-weighted images (A, unenhanced; B, arterial phase; C, venous phase; D, equilibrium phase) show progressive enhancement of inflammatory process in pancreaticoduodenal groove (arrows), characteristic of fibrous tissue.

 

Figure 10
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  		Fig. 5A —31-year-old woman with segmental form of groove pancreatitis. Unenhanced and dynamic contrast-enhanced axial fast spoiled gradient-echo fat-suppressed T1-weighted images (A, unenhanced; B, arterial phase; C, venous phase; D, equilibrium phase) show inflammatory process in pancreaticoduodenal space and enlargement of pancreatic head, which has low signal intensity because of chronic pancreatitis (arrows).

 

Figure 11
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  		Fig. 5B —31-year-old woman with segmental form of groove pancreatitis. Unenhanced and dynamic contrast-enhanced axial fast spoiled gradient-echo fat-suppressed T1-weighted images (A, unenhanced; B, arterial phase; C, venous phase; D, equilibrium phase) show inflammatory process in pancreaticoduodenal space and enlargement of pancreatic head, which has low signal intensity because of chronic pancreatitis (arrows).

 

Figure 12
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  		Fig. 5C —31-year-old woman with segmental form of groove pancreatitis. Unenhanced and dynamic contrast-enhanced axial fast spoiled gradient-echo fat-suppressed T1-weighted images (A, unenhanced; B, arterial phase; C, venous phase; D, equilibrium phase) show inflammatory process in pancreaticoduodenal space and enlargement of pancreatic head, which has low signal intensity because of chronic pancreatitis (arrows).

 

Figure 13
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  		Fig. 5D —31-year-old woman with segmental form of groove pancreatitis. Unenhanced and dynamic contrast-enhanced axial fast spoiled gradient-echo fat-suppressed T1-weighted images (A, unenhanced; B, arterial phase; C, venous phase; D, equilibrium phase) show inflammatory process in pancreaticoduodenal space and enlargement of pancreatic head, which has low signal intensity because of chronic pancreatitis (arrows).

 

Figure 14
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  		Fig. 6A —48-year-old woman with pancreatic adenocarcinoma. Mass in pancreaticoduodenal groove has low signal on fat-suppressed fast spoiled gradient-echo T1-weighted image (arrow, A) and high heterogeneous signal intensity on coronal single-shot fast spin-echo (TE, 90) T2-weighted image (asterisk, B).

 

Figure 15
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  		Fig. 6B —48-year-old woman with pancreatic adenocarcinoma. Mass in pancreaticoduodenal groove has low signal on fat-suppressed fast spoiled gradient-echo T1-weighted image (arrow, A) and high heterogeneous signal intensity on coronal single-shot fast spin-echo (TE, 90) T2-weighted image (asterisk, B).

 

Figure 16
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  		Fig. 6C —48-year-old woman with pancreatic adenocarcinoma. Thick-slab MRCP image (TE, 800) shows abrupt stenosis of common bile duct at level of mass. Postoperative diagnosis was pancreatic adenocarcinoma infiltrating duodenal wall and pancreaticoduodenal groove, which is main differential diagnosis with groove pancreatitis.

 
Inflammatory Changes in Pancreatic Parenchyma
Hypointensity of the pancreatic head or the entire gland on T1-weighted images is observed (Fig. 7A), usually associated with parenchymal atrophy and ductal dilatation (Fig. 7B). This finding reflects the chronic aspect of inflammatory disease, leading to progressive loss of glandular cells, protein, and lipidic contents of the gland, which are replaced by fibrous tissue. Some patients may present with enlargement of the pancreatic head. In the pure form of groove pancreatitis, the pancreas itself is spared and shows the usual bright T1 signal intensity.


Figure 17
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  		Fig. 7A —41-year-old man with groove pancreatitis. T1-weighted fast spoiled gradient-echo image shows hypointensity and volume loss of pancreatic parenchyma.

 

Figure 18
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  		Fig. 7B —41-year-old man with groove pancreatitis. T2-weighted fast spin-echo image with respiratory triggering (TR range/TE, 4,000–6,000/160) better depicts dilated main pancreatic duct, commonly seen in chronic pancreatitis.

 
Cysts
Cystic lesions are well shown in the groove or duodenal wall, especially on T2-weighted images. MR cholangiopancreatography (MRCP) also depicts the relationship between the ductal system and the cystic changes (Figs. 8A and 8B).


Figure 19
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  		Fig. 8A —33-year-old woman with groove pancreatitis. T2-weighted image (A) and thick-slab coronal MR cholangiopancreatography image (B) show cysts in duodenal wall and in pancreaticoduodenal groove (arrows, B). Also note stenosis of descending duodenum in B.

 

Figure 20
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  		Fig. 8B —33-year-old woman with groove pancreatitis. T2-weighted image (A) and thick-slab coronal MR cholangiopancreatography image (B) show cysts in duodenal wall and in pancreaticoduodenal groove (arrows, B). Also note stenosis of descending duodenum in B.

 
Duodenal Wall Thickening and Duodenal Stenosis
MRCP and cross-sectional images can show duodenal morphology and correlate it with the tissue in the groove (Figs. 8B, 9A, and 9B). Duodenal evaluation is important in differentiating groove pancreatitis from pancreatic cancer because marked inflammatory duodenal parietal thickening is not a common feature associated with tumors in the pancreatic head.


Figure 21
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  		Fig. 9A —34-year-old woman with groove pancreatitis. Coronal single-shot fast spin-echo T2-weighted image (A) and thick-slab coronal MR cholangiopancreatography image (B) show duodenal wall thickening and stenosis (arrows).

 

Figure 22
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  		Fig. 9B —34-year-old woman with groove pancreatitis. Coronal single-shot fast spin-echo T2-weighted image (A) and thick-slab coronal MR cholangiopancreatography image (B) show duodenal wall thickening and stenosis (arrows).

 
Common Bile Duct Tapering
Some degree of stenosis is virtually always found. This tapering is characteristically regular (Figs. 10A, 10B, and 10C) in contrast to the abrupt and "shouldered" aspect of stenosis in pancreatic cancers (Figs. 6A, 6B, and 6C). Sometimes the stenosis leads to a mild retrograde biliary dilatation.


Figure 23
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  		Fig. 10A —35-year-old man with groove pancreatitis. Thick-slab coronal MR cholangiopancreatography images (A and B) and coronal single-shot fast spin-echo T2-weighted image (C) show common bile duct tapering (arrows), which is typical of chronic pancreatitis.

 

Figure 24
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  		Fig. 10B —35-year-old man with groove pancreatitis. Thick-slab coronal MR cholangiopancreatography images (A and B) and coronal single-shot fast spin-echo T2-weighted image (C) show common bile duct tapering (arrows), which is typical of chronic pancreatitis.

 

Figure 25
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  		Fig. 10C —35-year-old man with groove pancreatitis. Thick-slab coronal MR cholangiopancreatography images (A and B) and coronal single-shot fast spin-echo T2-weighted image (C) show common bile duct tapering (arrows), which is typical of chronic pancreatitis.

 
Pancreatic Duct Morphology
The main pancreatic duct usually shows a mild, regular, and progressive pattern of narrowing in the head of the gland, especially in the segmental form of the disease (Fig. 11A). Higher degrees of dilation of the Wirsung duct and secondary duct ectasia are seen in some patients (Fig. 11B), a fact that can be explained by the inclusion of cases when both groove pancreatitis and diffuse chronic inflammatory disease were present.


Figure 26
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  		Fig. 11A —37-year-old woman and 40-year-old man with groove pancreatitis. Coronal thick-slab MRCP images show two patients with dilation and tortuosity of main and secondary pancreatic ducts and narrowing of distal segments. Also note, in B, pancreas divisum is characterized by ventral duct that drains via major papilla and has no communication with remaining pancreatic ductal system (arrow, B).

 

Figure 27
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  		Fig. 11B —37-year-old woman and 40-year-old man with groove pancreatitis. Coronal thick-slab MRCP images show two patients with dilation and tortuosity of main and secondary pancreatic ducts and narrowing of distal segments. Also note, in B, pancreas divisum is characterized by ventral duct that drains via major papilla and has no communication with remaining pancreatic ductal system (arrow, B).

 
Widening of Space Between Distal Pancreatic and Common Bile Ducts and Duodenal Lumen on MRCP
This sign, not commonly seen in cases of pancreatic cancer, was observed in most of our patients with groove pancreatitis. We consider it to be caused by a combination of two factors: the presence of a space-occupying lesion in the pancreaticoduodenal groove and marked duodenal wall thickening (Figs. 12A and 12B).


Figure 28
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  		Fig. 12A —33-year-old man with groove pancreatitis. Coronal single-shot fast spin-echo T2-weighted image (A) and maximum-intensity-projection coronal single-shot fast spin-echo MR cholangiopancreatography image (B) show widening of distance between duodenal lumen and distal ducts (arrows) caused by inflammatory tissue in pancreaticoduodenal groove.

 

Figure 29
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  		Fig. 12B —33-year-old man with groove pancreatitis. Coronal single-shot fast spin-echo T2-weighted image (A) and maximum-intensity-projection coronal single-shot fast spin-echo MR cholangiopancreatography image (B) show widening of distance between duodenal lumen and distal ducts (arrows) caused by inflammatory tissue in pancreaticoduodenal groove.

 
Banana-Shaped Gallbladder
Because groove pancreatitis is not usually associated with a significant degree of biliary dilatation, the gallbladder tends to be normally distended. A curious fact is the high prevalence of a banana-shaped gallbladder on MRCP, a sign commonly encountered in cases of chronic pancreatitis (Figs. 13A, 13B, and 13C).


Figure 30
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  		Fig. 13A —34-year-old woman with groove pancreatitis. Coronal single-shot fast spin-echo T2-weighted (A), coronal fat-suppressed contrast-enhanced spoiled gradient-echo (minimum TR and TE) (B), and thick-slab single-shot fast spin-echo MR cholangiopancreatography (C) images reveal banana-shaped gallbladder.

 

Figure 31
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  		Fig. 13B —34-year-old woman with groove pancreatitis. Coronal single-shot fast spin-echo T2-weighted (A), coronal fat-suppressed contrast-enhanced spoiled gradient-echo (minimum TR and TE) (B), and thick-slab single-shot fast spin-echo MR cholangiopancreatography (C) images reveal banana-shaped gallbladder.

 

Figure 32
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  		Fig. 13C —34-year-old woman with groove pancreatitis. Coronal single-shot fast spin-echo T2-weighted (A), coronal fat-suppressed contrast-enhanced spoiled gradient-echo (minimum TR and TE) (B), and thick-slab single-shot fast spin-echo MR cholangiopancreatography (C) images reveal banana-shaped gallbladder.

 

Conclusion
Top
 Abstract
 Introduction
 MRI Findings of Groove...
 Conclusion
References
 
Groove pancreatitis is classified as a rare disease, but this might be partly due to lack of awareness of this condition. We consider MRI the best single comprehensive study to evaluate the many aspects of the disease, and knowledge of these aspects may help radiologists reach the correct diagnosis and avoid unnecessary surgical procedures.

When a mass presents with imaging features of fibrotic tissue in the pancreaticoduodenal space and is associated with duodenal stenosis, cysts, and regular tapering of the pancreatic and common bile ducts, radiologists should consider the possibility of groove pancreatitis.


Acknowledgments
 
We thank Walther Ishikawa, M.D., for the drawings in Figures 1A and 1B.


References
Top
 Abstract
 Introduction
 MRI Findings of Groove...
 Conclusion
 References
 

  1. Irie H, Honda H, Kuroiwa T, et al. MRI of groove pancreatitis. J Comput Assist Tomogr 1998;22 : 651-655[CrossRef][Medline]
  2. Stolte M, Weiss W, Volkholz H, Rosch W. A special form of segmental pancreatitis: "groove pancreatitis." Hepatogastroenterology 1982;29 : 198-208[Medline]
  3. Becker V. Bauchspeicheldruse (Inselapperat ausgenommen). In: Doerr W, ed. Spezielle pathologische Anatomie. Berlin, Germany: Springer, 1973
  4. Shudo R, Yazaki Y, Sakurai S, et al. Groove pancreatitis: report of a case and review of the clinical and radiologic features of groove pancreatitis reported in Japan. Intern Med2002; 41:537 -542[Medline]
  5. Yamaguchi K, Tanaka M. Groove pancreatitis masquerading as pancreatic carcinoma. Am J Surg 1992;163 : 312-316; discussion 317-318[CrossRef][Medline]
  6. 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 : 911-915[Medline]
  7. Becker V, Mischke U. Groove pancreatitis. Int J Pancreatol 1991; 10:173 -182[Medline]
  8. Adsay NV, Zamboni G. Paraduodenal pancreatitis: a clinico-pathologically distinct entity unifying "cystic dystrophy of heterotopic pancreas," "paraduodenal wall cyst," and "groove pancreatitis." Semin Diagn Pathol2004; 21:247 -254[CrossRef][Medline]
  9. Chatelain D, Vibert E, Yzet T, et al. Groove pancreatitis and pancreatic heterotopia in the minor duodenal papilla. Pancreas 2005; 30:e92 -e95[CrossRef][Medline]
  10. Tio TL, Luiken GJ, Tytgat GN. Endosonography of groove pancreatitis. Endoscopy 1991;23 : 291-293[Medline]
  11. Ito K, Koike S, Matsunaga N. MR imaging of pancreatic diseases. Eur J Radiol 2001;38 : 78-93[CrossRef][Medline]

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