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Pancreas divisum

Pancreas divisum (PD) represents a variation in panctreatic ductal anatomy that can cause symptoms.

Epidemiology

It is most common variation of pancreatic duct formation and may be present in ~ 4-10 % of the general population 3-4,6. It's MRCP prevalence is at around 9 with autospy prevalence going upto 14% 7.

Clinical presentation

Most patients with a pancreas divisum are asymptomatic but is more frequently seen in patients with chronic abdominal pain and idiopathic pancreatitis than in the general population 4.

Pathology

It results from failure of fusion of dorsal and ventral pancreatic anlages. As a result, the dorsal pancreatic duct drains most of the pancreatic glandular parenchyma via the minor papilla. Although controversial, this variant is considered as a cause of  pancreatitis. 

Pancreatic divisum can result in a santorinicele , which is a cystic dilatation of the distal dorsal duct, immediately proximal to the minor papilla . 

Three sub types are known

  • type 1 (classic) - no connection at all; occurs in the majority of cases: 70% 
  • type 2 (absent ventral duct) - minor papilla drain all of pancreas while major papilla drains bile duct; 20-25% 
  • type 3 (functional) - filamentous or inadequate connection between dorsal and ventral ducts: 5-6%

Radiographic features

Fluoroscopy - ERCP

This was the traditional method of diagnosis where a pancreac divisum was suspected when there was no contrast extending towards the pancreatic tail uopn adminstration at the ampulla of Vater.

MRCP - MRI pancreas

This is the standard method of evaluation in modern times.

The key imaging features are

  • the dorsal pancreatic duct being in direct continuity with the duct of Santorini, which drains into the minor ampulla
  • ventral duct, which does not communicate with the dorsal duct but joins with the distal bile duct to enter the major ampulla

Some authors suggest increased sensitivity of secretin MRCP (S-MRCP) in detection sensitivity of pancreas divisum 2.

Treatment and prognosis

There are several managment options in selcted cases which include 6

  • minor papilectomy
  • minor papilla stenting
  • balloon dilatation of an any associated stricture

More content required on prognosis


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