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Pancreas divisum

Dr Craig Hacking ◉ ◈ and Dr Yuranga Weerakkody ◉ et al.

Pancreas divisum represents a variation in pancreatic ductal anatomy that can be associated with abdominal pain and idiopathic pancreatitis. It is characterized, in the majority of cases, by the dorsal pancreatic duct (main pancreatic and Santorini ducts) directly entering the minor papilla with no communication with the ventral duct (Wirsung), and thus, the major papilla.

On this page:

Article:

Terminology
Epidemiology
Clinical presentation
Pathology
Radiographic features
Treatment and prognosis
Related articles
References

Images:

Cases and figures

Terminology

The term dominant dorsal duct syndrome is sometimes used in the literature to reflect that the main pancreatic duct draining via the minor papilla does not always have the classical pancreas divisum anatomy ⁸.

The classic description of pancreas divisum refers to the complete form but incomplete and reverse forms have also been described (see figures 2 to 4).

Epidemiology

It is the most common variation of pancreatic duct formation and may be present in ~4-10 % of the general population ^3-4,6. Its MRCP prevalence is at around 9% with autopsy prevalence going up to 14%⁷.

Clinical presentation

Most people with a pancreas divisum are asymptomatic, but this is more frequently found 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 santorinicoele, which is a cystic dilatation of the distal dorsal duct (Santorini duct), immediately proximal to the minor papilla.

Three subtypes are known:

type 1 (classic): no connection at all; occurs in the majority of cases: 70%
type 2 (absent ventral duct): minor papilla drains 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%

A reverse pancreas divisum has been described where the main duct fuses with the ventral duct and a small residue dorsal duct does not communicate with the main duct and drains separately into the minor papilla ^{9, 10}.

Radiographic features

Fluoroscopy: ERCP

This was the traditional method of diagnosis where a pancreas divisum was suspected when there was no contrast extending towards the pancreatic tail upon administration at the ampulla of Vater.

MRCP/MRI pancreas

It is the current gold standard method of evaluation. The key imaging features:

the dorsal pancreatic duct being in direct continuity with the duct of Santorini, which drains into the minor ampulla
ventral duct (Wirsung 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

A diagnosis of pancreas divisum does not routinely warrant treatment, especially when incidental and asymptomatic. In symptomatic patients (e.g. recurrent pancreatitis), management options may include ⁶:

non-operative treatment +/- pancreatic enzyme supplements
minor papillectomy
minor papilla stenting
balloon dilatation of any associated stricture

Quiz questions

References

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
8. Warshaw AL, Simeone JF, Schapiro RH, Flavin-Warshaw B. Evaluation and treatment of the dominant dorsal duct syndrome (pancreas divisum redefined). (1990) American journal of surgery. 159 (1): 59-64; discussion 64-6. Pubmed
9. Ferri V, Vicente E, Quijano Y, Ielpo B, Duran H, Diaz E, Fabra I, Caruso R. Diagnosis and treatment of pancreas divisum: A literature review. (2019) Hepatobiliary & pancreatic diseases international : HBPD INT. doi:10.1016/j.hbpd.2019.05.004 - Pubmed
10. Adibelli ZH, Adatepe M, Imamoglu C, Esen OS, Erkan N, Yildirim M. Anatomic variations of the pancreatic duct and their relevance with the Cambridge classification system: MRCP findings of 1158 consecutive patients. (2016) Radiology and oncology. 50 (4): 370-377. doi:10.1515/raon-2016-0041 - Pubmed

Anatomy: Abdominopelvic

skeleton of the abdomen and pelvis
muscles of the abdomen and pelvis
spaces of the abdomen and pelvis
- anterior abdominal wall
  - sternocostal triangle
- posterior abdominal wall
- abdominal cavity
  - peritoneum
  - retroperitoneum
- pelvic cavity
  - pelvic peritoneal space
    - rectouterine pouch (pouch of Douglas)
    - rectovesical pouch
  - retropubic space (of Retzius)
  - paravesical space
    - lateral fossa
    - supravesical fossa
  - presacral space
  - canal of Nuck
  - pudendal canal
  - obturator canal
- perineum
abdominal and pelvic viscera
blood supply of the abdomen and pelvis
lymphatics
- lymph node groups
- cisterna chyli
innervation of the abdomen and pelvis
- lumbar plexus
- sacral plexus

Article information

rID: 18365

System: Hepatobiliary

Section: Anatomy

Tag: pancreas, variants

Synonyms or Alternate Spellings:

Dominant dorsal duct syndrome
Pancreatic divisum
Pancreas divisum (PD)
Divisum of pancreas

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Cases and figures

Figure 1: pancreatic divisum Figure 1: pancreatic divisum

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Figure 2: complete pancreatic divisumFigure 2: complete pancreatic divisum

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Figure 3: incomplete pancreatic divisumFigure 3: incomplete pancreatic divisum

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Figure 2: reverse pancreatic divisumFigure 2: reverse pancreatic divisum

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Case 1Case 1

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Long TE SS-FSE th...

Case 2Case 2

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Case 3Case 3

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Pancreas divisum

Case 4Case 4

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Case 5Case 5

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Case 6Case 6

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Case 7: coronal source image from 3D MRCPCase 7: coronal source image from 3D MRCP

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Case 8 Case 8

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Case 9: with cholelithiasisCase 9: with cholelithiasis

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Case 10Case 10

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Case 11Case 11

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Case 12Case 12

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