A pancreas divisum (PD) is variation in panctreatic ductal anatomy.
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.
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.
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 %
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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- 1. Soto JA, Lucey BC, Stuhlfaut JW. Pancreas divisum: depiction with multi-detector row CT. Radiology. 2005;235 (2): 503-8. doi:10.1148/radiol.2352040342 - Pubmed citation
- 2. Manfredi R, Costamagna G, Brizi MG et-al. Pancreas divisum and "santorinicele": diagnosis with dynamic MR cholangiopancreatography with secretin stimulation. Radiology. 2000;217 (2): 403-8. Radiology (citation) - Pubmed citation
- 3. Soulen MC, Zerhouni EA, Fishman EK et-al. Enlargement of the pancreatic head in patients with pancreas divisum. Clin Imaging. 1989;13 (1): 51-7. Clin Imaging (link) - Pubmed citation
- 4. Mortelé KJ, Rocha TC, Streeter JL et-al. Multimodality imaging of pancreatic and biliary congenital anomalies. Radiographics. 26 (3): 715-31. doi:10.1148/rg.263055164 - Pubmed citation
- 5. Bret PM, Reinhold C, Taourel P et-al. Pancreas divisum: evaluation with MR cholangiopancreatography. Radiology. 1996;199 (1): 99-103. Radiology (citation) - Pubmed citation
- 6. Morgan DE, Logan K, Baron TH et-al. Pancreas divisum: implications for diagnostic and therapeutic pancreatography. AJR Am J Roentgenol. 1999;173 (1): 193-8. AJR Am J Roentgenol (citation) - Pubmed citation
- 7. Yu J, Turner MA, Fulcher AS et-al. Congenital anomalies and normal variants of the pancreaticobiliary tract and the pancreas in adults: part 2, Pancreatic duct and pancreas. AJR Am J Roentgenol. 2006;187 (6): 1544-53. doi:10.2214/AJR.05.0774 - Pubmed citation
Synonyms & Alternative Spellings
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