Presentation
Recurrent upper abdominal pain radiating to back. Amylase normal, liver enzymes normal. Ultrasound normal, plain CT - no calculus, swelling or fluid collection.
Patient Data
Cystic duct is elongated and tortuous, with low medial insertion into common hepatic duct approx. 18 mm proximal to the ampulla.
Common bile duct inserts into major duodenal papilla alone.
Main pancreatic duct (MPD) continues with dorsal pancreatic duct (of Santorini) and inserts into minor duodenal papilla. Uncinate duct joins dorsal pancreatic duct and also drains into minor duodenal papilla.
Ventral pancreatic duct (of Wirsung) is absent.
MRCP
Cystic duct is elongated and tortuous, with low medial insertion into common hepatic duct approx. 18 mm proximal to the ampulla.
Common bile duct inserts into major duodenal papilla alone.
Main pancreatic duct (MPD) continues with dorsal pancreatic duct (of Santorini) and inserts into minor duodenal papilla. Uncinate duct joins dorsal pancreatic duct and also drains into minor duodenal papilla.
Ventral pancreatic duct (of Wirsung) is absent.
Case Discussion
The MRCP findings now explain the hitherto unexplained (i.e. all reports normal) presentation of recurrent episodes of pancreatic-type abdominal pain. The narrow lumen of the minor papilla produces back-pressure on the pancreatic parenchyma 1, resulting in recurrent bouts of acute interstitial pancreatitis. Papillotomy and/or dilatation may effectively resolve the problems.
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