Pictorial Essay

Normal Anatomy and Disease Processes of the

Pancreatoduodenal Groove: Imaging Features
Jinxing Yu1, Ann S. Fulcher, Mary Ann Turner, Robert A. Halvorsen

T he pancreatoduodenal groove is a
potential space bordered by the
head of the pancreas, duodenum,
and common bile duct [1–3] (Fig. 1). Diseases
bile duct lies either in the parenchyma of the
pancreatic head or adjacent to the posterior as-
pect of the pancreatic head, the distal common
bile duct traverses the posterior aspect of the
der of the pancreatoduodenal groove is formed
by the first portion of the duodenum and at
times by the gastric antrum. Normally, there
are small lymph nodes in the groove that are
arising from or involving the pancreatoduode- pancreatoduodenal groove. The anterior bor- not generally depicted on imaging.
nal groove can be categorized into four types:
diseases associated with the pancreas, duode-
num, lymph nodes, and distal common bile
duct. We present the key diagnostic findings
of these diseases, along with features that can
be used to distinguish among them, in this
pictorial essay. Knowledge of the features of
each disease may allow one to make a specific
diagnosis, which assists in clinical manage-
ment and helps to prevent unnecessary surgi-
cal intervention.

Anatomy
The specific borders of the pancreatoduode-
nal groove are as follows: The medial border
of the pancreatoduodenal groove is formed by
the pancreatic head. The serosal surface of the
descending duodenum is intimately related to
the pancreatic head and forms the lateral bor-
der of the pancreatoduodenal groove (Fig. 2).
The posterior border of the groove is formed
Fig. 1.—Schematic drawing of anatomy of pancreatoduodenal groove. Arrowheads indicate groove formed by
by the third portion of the duodenum or by the junction of pancreatic head (P), duodenum (D), and bile duct (B). Arrows indicate small lymph nodes, normally
inferior vena cava. Because the distal common present in groove.

Received July 9, 2003; accepted after revision April 26, 2004.

1
All authors: Department of Radiology, Abdominal Imaging Section, Virginia Commonwealth University, Medical College of Virginia Hospitals and Physicians, 1250 E Marshall St.,
PO Box 980615, Richmond, VA 23298-0615. Address correspondence to J. Yu (jiyu@hsc.vcu.edu).
AJR 2004;183:839–846 0361–803X/04/1833–839 © American Roentgen Ray Society

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 Yu et al.

A B
Fig. 2.—Normal anatomy of pancreatoduodenal groove in healthy 46-year-old woman. P = pancreatic head, D = duodenum.
A, Axial CT scan of abdomen shows potential space (arrows) between pancreatic head and duodenum.
B, Axial T2-weighted image shows duodenum, pancreatic head, and groove (arrows).

A B

C D
Fig. 3.—Groove pancreatitis in 47-year-old man with history of pancreatitis. P = pancreatic head, D = duodenum.
A, Axial T2-weighted image shows groove pancreatitis (arrows) that is slightly hyperintense relative to pancreatic head and contains focal areas of markedly increased
signal intensity.
B, Axial T1-weighted image indicates lesion (arrows) with low signal intensity between pancreatic head and duodenum.
C, Dynamic axial MR image obtained during arterial phase after IV administration of gadolinium shows minimal enhancement of lesion (arrows) between pancreatic head
and duodenum.
D, Delayed contrast-enhanced axial T1-weighted MR image obtained 5 min after injection of gadolinium shows partial enhancement of lesion (arrows) between duodenum
and pancreatic head.

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 Imaging Features of the Pancreatoduodenal Groove

A B

Fig. 4.—Cystic dystrophy of duodenal wall in 58-year-old man with history of pancreatitis.
A, Axial CT scan shows cystic lesion (solid arrows) in thickened duodenal wall with peripheral enhancement. Cystic lesion is lateral
relative to pancreatic head and medial relative to duodenal lumen. Inflammation in anterior pararenal space (open arrow) is caused
by pancreatitis. P = pancreatic head, D = duodenum.
B, Coronal MR cholangiopancreatographic image shows high-signal-intensity cystic lesion (solid arrows) in duodenal wall medial to
gallbladder (G) and anterior and lateral to common bile duct. Open arrow indicates common hepatic duct. Diagnosis of cystic dystro-
phy of duodenal wall was confirmed surgically.

Diseases Associated with the Pancreas
Groove Pancreatitis
Groove pancreatitis is a form of chronic
segmental pancreatitis affecting the groove in
the region of the pancreatic head, duodenum,
and common bile duct [1–3]. There are two
forms of groove pancreatitis: pure and seg-
mental. The pure form of groove pancreatitis
affects the groove only, and the segmental
form involves the head of the pancreas, with
scar tissue located in the groove [3]. The
pathogenesis of groove pancreatitis remains
unclear, although several factors such as peptic
ulcers, gastric resection, true duodenal-wall
cysts, and pancreatic heterotopia in the duode-
nal wall may be related to this condition [3].
On IV contrast–enhanced CT or MRI, soft-tis-
sue-attenuation material with delayed en-
hancement is noted between the pancreatic
head and the adjacent duodenum [1, 2] (Fig.
3). Irie et al. [1] described the MRI features of
five patients with groove pancreatitis. They
noted a sheetlike mass in the pancreatoduode-
nal groove that was hypointense relative to the
pancreatic parenchyma on T1-weighted im-
ages and isointense or slightly hyperintense on
T2-weighted images. Histologic analysis re-
vealed that these imaging features correlated
with fibrous scar in each of the five patients.
Cystic dystrophy of the duodenal wall, an
entity that is most likely related to groove pan-
creatitis, is characterized by the presence of
cystic lesions in the thickened wall of the sec-

A B

Fig. 5.—Fluid collection evolving into pseudocyst in pancreatoduodenal groove in 47-year-old man with acute pancreatitis. P = pancreatic head, D = duodenum.
A, Axial CT scan reveals small amount of fluid (arrows) in groove between pancreatic head and duodenum.
B, Axial CT scan obtained 6 weeks after A shows small pseudocyst formation (arrows) in groove between pancreatic head and duodenum.

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 Yu et al.

ond portion of the duodenum (Fig. 4). The
thickening of the duodenal wall appears as a
solid layer between the duodenal lumen and
the pancreas that exhibits delayed enhance-
ment on contrast-enhanced CT [4]. The
macro- and microscopic features of groove
pancreatitis reported in the literature [1–3] are
quite similar to those reported for cystic dys-
trophy of the duodenal wall [4].
The differentiation of groove pancreatitis
(especially the segmental form) from pancre-
atic carcinoma may be difficult, particularly
in those cases of pancreatic carcinoma that
have a significant fibrous component and
therefore may display delayed enhancement
similar to that seen with groove pancreatitis.
On MR cholangiopancreatography, the intra-
pancreatic portion of the bile duct in patients
with groove pancreatitis has a long, smooth,
narrowed configuration, in contrast to the
abrupt, circumscribed, irregular ductal steno-
sis or complete ductal obstruction seen in pa-
tients with pancreatic carcinoma.
Acute Pancreatitis
Acute pancreatitis with fluid collections
and inflammation in the peripancreatic
spaces, including in the pancreatoduodenal
groove (Fig. 5), is different from groove pan-
creatitis. Fluid collections and inflammation
in the groove from acute pancreatitis exhibit
rapid interval change on serial imaging stud-
ies and have high signal intensity on T2-
weighted imaging.
Exophytic Pancreatic Ductal Adenocarcinoma
Ductal adenocarcinoma of the pancreatic
head sometimes may present as an exophytic
mass that appears to arise from the pancre-
atoduodenal groove (Fig. 6). Key features of
exophytic pancreatic ductal adenocarcinoma
on CT and MRI that help to narrow the differ-
ential diagnosis from other entities affecting
the groove include a mass that is inseparable
from the pancreatic head, obstruction of com-
mon bile and pancreatic ducts, and adjacent
vascular encasement.
Neuroendocrine Tumor
The pancreatoduodenal groove is an impor-
tant space within the gastrinoma triangle whose
vertices are the cystic duct confluence, the junc-
tion of the pancreatic neck and body, and the
junction of the second and third portions of the
duodenum [1, 5]. Gastrinoma is the most com-
mon neuroendocrine tumor occurring at the
groove. On dynamic contrast-enhanced CT or
MRI, neuroendocrine tumors enhance to a
greater degree than normal pancreatic paren-
chyma during the arterial and capillary phases
(Fig. 7). The features that distinguish neuroen-
docrine tumors and specifically gastrinomas
from ductal adenocarcinomas include intense

A B

Fig. 6.—Exophytic pancreatic ductal adenocarcinoma in 45-year-old man.

A, Axial CT scan shows exophytic mass (arrow) in pancreatoduodenal groove that is inseparable
from pancreatic head and medial wall of duodenum. P = pancreatic head, D = duodenum.
B, Coronal MR cholangiopancreatographic image reveals obstruction of distal common bile duct
(arrow) with dilatation of more proximal biliary duct (C) and gallbladder (G).
C, Coronal MR cholangiopancreatographic image shows obstruction of pancreatic duct at pancre-
atic head (solid arrow). Extrahepatic hepatic bile duct (C), intrahepatic ducts (open arrows), and
gallbladder (G) are dilated.
C

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 Imaging Features of the Pancreatoduodenal Groove

A B

Fig. 7.—Surgically proven pancreatoduodenal groove gastrinoma extending into ampulla of Vater and duodenum with large duodenal hematoma in 50-year-old man. P =
pancreatic head, D = duodenum, G = gallbladder.
A, Contrast-enhanced axial CT scan shows enhancing mass (arrows) in pancreatoduodenal groove lateral to pancreatic head and medial to duodenum.
B, Contrast-enhanced axial CT scan shows mass (solid arrows) associated with large duodenal hematoma (open arrow).

A B

Fig. 8.—Duodenal diverticulum in 70-year-old woman who was being evaluated for possible pancreatic mass seen on prior chest CT study.
A, Air–fluid level (arrows) is medial relative to second portion of duodenum (D), anterior relative to inferior vena cava, and lateral relative to pancreas (P) on axial CT scan.
B, Coronal MR cholangiopancreatographic scan shows diverticulum with low signal intensity (single solid arrows) consistent with air. Diverticulum exerts mass effect on
distal common bile duct (open arrow). Double solid arrows indicate pancreatic duct.

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 Yu et al.

A B

Fig. 9.—Exophytic duodenal adenocarcinoma in 59-year-old woman. D = duodenum, P = pancreatic head.

A, Contrast-enhancing mass (arrows) in pancreatoduodenal groove is medial relative to dilated duodenum and lateral relative to pancreatic head on axial CT scan. Duode-
nal dilatation is reflective of obstruction.
B, Axial CT scan obtained at level inferior to A shows enhancing mass (arrows) between pancreatic head and duodenum. Surgery confirmed diagnosis of exophytic duode-
nal adenocarcinoma.

homogeneous early enhancement on CT or
MRI, high signal intensity on T2-weighted
MRI, location of the mass within the gastri-
noma triangle and perhaps even within the pan-
creatoduodenal groove, and hypervascular liver
metastases [5].
Diseases Associated with the Duodenum
Duodenal Diverticulum
Duodenal diverticula typically occur in the
periampullary region, along the medial aspect
of the second and third portions of the duode-
num in the pancreatoduodenal groove [6]. A
duodenal diverticulum may mimic other
groove diseases such as tumor or a pancreatic
pseudocyst or abscess [4]. Duodenal divertic-
ula may also occasionally become impacted
with debris, leading to duodenal diverticulitis,
which presents as an inflammatory process in

Fig. 10.—Metastatic lymphadenopathy in 62-year-old man with history of lung car- Fig. 11.—Non-Hodgkin’s lymphoma in 41-year-old man. Axial CT scan reveals large
cinoma. On axial CT scan, necrotic lymph node (solid arrows) is seen in pancre- mass (M) medial relative to duodenum (D) and lateral and posterior relative to pan-
atoduodenal groove between duodenum (D) and pancreatic head (P). Liver creatic head (P), consistent with enlarged lymph node. Metallic biliary stent (arrow)
metastasis (M) and necrotic peritoneal metastasis (open arrow) are noted. is seen in common bile duct.

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 Imaging Features of the Pancreatoduodenal Groove

Fig. 12.—Mycobacterium avium-intracellulare (MAI) infection in 35-year-old man

with AIDS. Axial CT scan shows several low-attenuation lymph nodes (arrows) in
pancreatoduodenal groove medial relative to duodenum (D) and lateral and poste-
rior relative to pancreatic head (P). Open biopsy confirmed diagnosis of MAI infec-
tion in lymph nodes. G = gallbladder.

the groove. Identifying intradiverticular oral
contrast material or a small amount of gas and
recognizing the communication with the
duodenum assists one in making the correct di-
agnosis (Fig. 8).
Exophytic Duodenal Adenocarcinoma
Adenocarcinoma may occur in the peri-
ampullary region of the duodenum. This tu-
mor tends to be polypoid [7] and may lie in
the pancreatoduodenal groove (Fig. 9). An
exophytic duodenal mass, duodenal mucosal
destruction at the upper gastrointestinal tract,
and common bile duct and proximal bowel
obstruction are the major imaging features
that are associated with this entity.
Diseases Associated with the
Lymph Nodes
Lymph nodes are located in the pancre-
atoduodenal groove. Specifically, the lym-
phatics of liver and biliary tract drain along
the hepatoduodenal ligament that inserts at or
near the pancreatoduodenal groove. Pancre-
atoduodenal nodes also receive lymphatic
drainage from adjacent structures such as the
duodenum and pancreas. Therefore, diseases
of the liver, biliary tract, duodenum, and pan-
creas may cause enlarged lymph nodes in the
pancreatoduodenal groove; these diseases in-
clude metastasis (Fig. 10), lymphoma (Fig.
11), and infection (Fig. 12). At times, differ-
entiating a solitary enlarged lymph node from

A B

Fig. 13.—Villous adenocarcinoma in periampullary region in 55-year-old woman.

A, Axial CT scan shows mass in region of distal common bile duct (arrows) between pancreas (P) and duodenum (D).
B, MR cholangiopancreatographic image reveals mass (arrows) in distal common bile duct (C) and pancreatic duct (P) that is medial relative to duodenum (D). G = gallbladder.

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a pancreatic tumor is difficult, although a tu-
mor often intrinsically involves and obstructs
the pancreatic and common bile ducts.
Diseases Associated with the Distal
Common Bile Duct
Cholangiocarcinoma
Distal common bile duct carcinoma may
present as a mass arising from the pancre-
atoduodenal groove. The key features of distal
cholangiocarcinoma are biliary ductal dilatation
terminating abruptly at a point of ductal wall
thickening or a polypoid mass. If the obstruc-
tion of the distal common bile duct is at the level
of the ampulla of Vater, it may be impossible to
be certain, even at histologic examination, if the
tumor originates from the bile duct, pancreas, or
duodenum [8] (Fig. 13).
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Yu et al.
Choledochal Cyst
Distal dilatation of the common bile duct
(choledochal cyst) may mimic a fluid collec-
tion in the pancreatoduodenal groove. An
abrupt change of caliber at the junction of
the dilated segment and normal ducts is com-
mon. Confirmation of the tubular dilated por-
tion of common bile duct communicating
with the hepatic ducts assists one in estab-
lishing the diagnosis.
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