Treatment of pancreas divisum
- Evan L Fogel, MD
Evan L Fogel, MD
- Professor of Medicine
- Indiana University School of Medicine
- Stuart Sherman, MD
Stuart Sherman, MD
- Professor of Medicine and Radiology
- Indiana University School of Medicine
Pancreas divisum is the most common congenital pancreatic anomaly, occurring in approximately 7 percent of subjects in autopsy series [1,2]. It is usually diagnosed during endoscopic retrograde cholangiopancreatography (ERCP), although magnetic resonance cholangiopancreatography (MRCP), especially with secretin stimulation, can detect more than 90 percent of such patients [3,4]. More than 95 percent of patients with pancreatic divisum are asymptomatic and it remains controversial whether the symptoms that occur in the remaining patients are etiologically related to pancreas divisum. (See "Anatomy and clinical significance of pancreas divisum".)
We believe that there is a group of patients with pancreas divisum who are subject to recurrent bouts of pancreatitis. Why such patients are at increased risk for recurrent pancreatitis is not well understood. In some, the minor papilla orifice may be so small that excessively high intrapancreatic dorsal ductal pressure occurs during active secretion, which may result in inadequate drainage, ductal distension, pain, and, in some cases, pancreatitis . It is possible that pancreas divisum can lead to chronic pancreatitis or "pancreatic" pain. Genetic studies have also suggested that as many as 10 to 20 percent of patients with pancreas divisum who have pancreatitis carry at least one allele of the cystic fibrosis gene product, suggesting a multifactorial origin of pancreatitis in such patients .
This topic review will discuss the two major therapeutic issues in symptomatic patients with pancreas divisum: the detection of pathologic minor papilla narrowing and the techniques and results of surgical and endoscopic approaches to correct the minor papilla narrowing. The anatomy and controversies surrounding the clinical significance of pancreas divisum are discussed separately. (See "Anatomy and clinical significance of pancreas divisum".)
DETECTION OF PATHOLOGIC MINOR PAPILLA NARROWING
The important diagnostic issue in a patient with pancreas divisum and pancreatic symptoms is whether there is remediable papillary narrowing. A number of methods have been used in an attempt to identify patients with pathologic papillary narrowing. These tests attempt to demonstrate dorsal duct dilation, papillary narrowing, increased papillary or ductal pressure, or the selective occurrence of pancreatitis in the dorsal as opposed to the ventral portion of the pancreas (table 1). The sensitivity and specificity of these tests are largely undefined and correlation with a response to therapy has not been clearly shown in most studies.
Computerized tomography scan — A standard computed tomography (CT) scan of the pancreas may identify dilation of the dorsal duct and/or changes of chronic pancreatitis that are confined to the dorsal area of the pancreas. More commonly, the CT scan just shows nonspecific prominence of the pancreatic head and is not of diagnostic value . Visualization of a fat plane between the dorsal and ventral portions can suggest pancreas divisum but does not generally separate symptomatic from coincidental states .
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- DETECTION OF PATHOLOGIC MINOR PAPILLA NARROWING
- Computerized tomography scan
- Secretin ultrasound
- Diagnostic endoscopic retrograde cholangiopancreatography (ERCP)
- Special ERCP techniques
- - Pancreatic juice collection
- - Papillary manometry
- - Therapeutic trial
- Intraoperative patency determination
- SURGICAL AND ENDOSCOPIC MANAGEMENT
- Surgical minor papilla sphincterotomy and sphincteroplasty
- Endoscopic minor papilla dilation and stenting
- Endoscopic minor papilla sphincterotomy
- SUMMARY AND RECOMMENDATIONS