Pancreas divisum as a cause of recurrent pancreatitis

Abstract

Presenter: Paula Morgade MD | Hospital Central de las Fuerzas Armadas Background: The pancreas develops from two separate intestinal outlines, one dorsal and one ventral. Main pancreatic duct arises from the tail of the pancreas and crosses the gland. Throughout its journey, smaller ducts flow into it. Accessory pancreatic duct drains the anterior superior portion of the head of the pancreas directly into the duodenum through the lesser papilla or into the duct of Wirsung. Pancreas divisum is the most common anatomical variant of the pancreas and is associated with recurrent acute pancreatitis. Pathological mechanism would be a disproportion between the amount of pancreatic secretion and the caliber of the duct (smaller), which could generate stasis, ductal distention and increase the risk of acute pancreatitis, which could be considered a predisposing factor for pancreatitis. Treatment goals consist in otpimizing pancreatic drainage. Modalities are endoscopic and surgical. The efficacy of endoscopic and surgical treatment is controversial. Endoscopic retrograde cholangiopancreatography (ERCP) is done for minor papila sphincterotomy, balloon dilation and eventual stent placement. Succes rates of vary between 31% to 96%. Surgery should be considered when endoscopic treatment fails. Even though surgery has more complications, it has better success rates improving symptoms and avoiding pancreatitis. Methods: 50yo female. Laparoscopic cholecystectomy 3 years ago after acute pancreatitis. Since then 10 more episodes of mild acute pancreatitis. No associated cholestasis. MRCP showed a dilated pancreatic duct (7mm) ending in the lesser papila (white arrow figure). Compatible with pancreas divisum as a probable cause of recurrent pancreatitis. Bile duct ends in major papila (grey arrow in figure) separatedly from pancreatic duct. ERCP was performed for stent placement in the minor papila, procedure failed because minor papila was not recognized. Endoscopic ultrasound was not available. Given recurrence of episodes impairing quality of life, surgery was proposed. Results: A classic Whipple procedure with Child-Tredeé reconstruction was performed. No intraoperative incidents. No postoperative complications. Discharge was at day 7. Histopatological analysis of the specimen was consistent with chronic pancreatitis. After 18 months patient is asymptomatic, no new episodes of pancreatitis. Conclusion: Pancreas divisum is an infrequent cause of pancreatitis, it must be considered as cause in recurrent non biliary pancreatitis. Surgery may be an option when endoscopic treatment fails.