Endoscopic botulinum toxin injection into the minor papilla for treatment of idiopathic recurrent pancreatitis in patients with pancreas divisum

Abstract

Background: In some patients with pancreas divisum, obstruction to the flow of pancreatic juice into the duodenum is the presumptive cause of acute recurrent pancreatitis. However, identification of those patients who may benefit from minor papilla sphincterotomy or stent placement is difficult. Methods: Five patients with acute recurrent pancreatitis and pancreas divisum were therefore treated by endoscopic injection of 50 units of botulinum toxin into the minor papilla in an outpatient setting. Results: Botulinum toxin injection was successfully performed on six occasions in 5 patients and no adverse effects were noted. Two patients relapsed after 9 and 10 months, respectively, but had definite relief of symptoms after needle-knife sphincterotomy. One patient relapsed 7 months after botulinum toxin injection but became symptom free again after a second botulinum toxin injection. Another patient is still in clinical remission 4 months after botulinum toxin administration, and 1 patient did not respond to either botulinum toxin administration or to sphincterotomy and stent placement. Conclusions: Endoscopic injection of botulinum toxin into the minor papilla in patients with pancreas divisum and acute recurrent pancreatitis is a safe procedure that is easy to perform and provides short-term relief in some patients. Response to botulinum toxin injection may predict whether patients with pancreas divisum and acute recurrent pancreatitis will benefit from other forms of endoscopic therapy.