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]. 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 due to pancreas divisum.
This topic will review the management of patients with pancreas divisum. The epidemiology, pathogenesis, clinical manifestations, and diagnosis of pancreas divisum are discussed separately. (See "Pancreas divisum: Clinical manifestations and diagnosis".)
APPROACH TO MANAGEMENT
Due to the uncertainty of pancreas divisum as a causative factor in acute or chronic pancreatitis or chronic abdominal pain and the risks associated with treatment, our approach to the patient with pancreas divisum varies based on the clinical presentation.
Asymptomatic patients — Asymptomatic patients in whom pancreas divisum is incidentally found on abdominal imaging (eg, computed tomography scan or magnetic resonance cholangiopancreatogram [MRCP]) and who have no abnormality of the pancreas or clinical history of pancreatitis require no additional evaluation or treatment of pancreas divisum. (See "Pancreas divisum: Clinical manifestations and diagnosis", section on 'Diagnostic evaluation'.)
Patients with minimal/infrequent symptoms — In patients with pancreas divisum and mild or infrequent bouts of pain, we suggest conservative management rather than treatment of the minor papilla narrowing associated with pancreas divisum. Conservative management includes a low-fat diet, analgesics, anticholinergics, and if necessary, pancreatic enzyme supplements. The management of acute and chronic pancreatitis is discussed in detail, separately. (See "Management of acute pancreatitis" and "Treatment of chronic pancreatitis".)
- Smanio T. Proposed nomenclature and classification of the human pancreatic ducts and duodenal papillae. Study based on 200 post mortems. Int Surg 1969; 52:125.
- Stimec B, Bulajić M, Korneti V, et al. Ductal morphometry of ventral pancreas in pancreas divisum. Comparison between clinical and anatomical results. Ital J Gastroenterol 1996; 28:76.
- Lehman GA, Sherman S, Nisi R, Hawes RH. Pancreas divisum: results of minor papilla sphincterotomy. Gastrointest Endosc 1993; 39:1.
- Lehman GA, Sherman S. Pancreas divisum. Diagnosis, clinical significance, and management alternatives. Gastrointest Endosc Clin N Am 1995; 5:145.
- Liao Z, Gao R, Wang W, et al. A systematic review on endoscopic detection rate, endotherapy, and surgery for pancreas divisum. Endoscopy 2009; 41:439.
- Bradley EL 3rd, Stephan RN. Accessory duct sphincteroplasty is preferred for long-term prevention of recurrent acute pancreatitis in patients with pancreas divisum. J Am Coll Surg 1996; 183:65.
- Warshaw AL, Simeone JF, Schapiro RH, Flavin-Warshaw B. Evaluation and treatment of the dominant dorsal duct syndrome (pancreas divisum redefined). Am J Surg 1990; 159:59.
- Madura JA. Pancreas divisum: stenosis of the dorsally dominant pancreatic duct. A surgically correctable lesion. Am J Surg 1986; 151:742.
- Lindström E, Ihse I. Dynamic CT scanning of pancreatic duct after secretin provocation in pancreas divisum. Dig Dis Sci 1990; 35:1371.
- Kanth R, Samji NS, Inaganti A, et al. Endotherapy in symptomatic pancreas divisum: a systematic review. Pancreatology 2014; 14:244.
- Attwell A, Borak G, Hawes R, et al. Endoscopic pancreatic sphincterotomy for pancreas divisum by using a needle-knife or standard pull-type technique: safety and reintervention rates. Gastrointest Endosc 2006; 64:705.
- Siegel JH, Cohen SA, Kasmin FE, Veerappan A. Stent-guided sphincterotomy. Gastrointest Endosc 1994; 40:567.
- Rashdan A, Fogel EL, McHenry L Jr, et al. Improved stent characteristics for prophylaxis of post-ERCP pancreatitis. Clin Gastroenterol Hepatol 2004; 2:322.
- Lans JI, Geenen JE, Johanson JF, Hogan WJ. Endoscopic therapy in patients with pancreas divisum and acute pancreatitis: a prospective, randomized, controlled clinical trial. Gastrointest Endosc 1992; 38:430.
- Ertan A. Long-term results after endoscopic pancreatic stent placement without pancreatic papillotomy in acute recurrent pancreatitis due to pancreas divisum. Gastrointest Endosc 2000; 52:9.
- Heyries L, Barthet M, Delvasto C, et al. Long-term results of endoscopic management of pancreas divisum with recurrent acute pancreatitis. Gastrointest Endosc 2002; 55:376.
- Ikenberry SO, Sherman S, Hawes RH, et al. The occlusion rate of pancreatic stents. Gastrointest Endosc 1994; 40:611.
- Johanson JF, Schmalz MJ, Geenen JE. Incidence and risk factors for biliary and pancreatic stent migration. Gastrointest Endosc 1992; 38:341.
- Johanson JF, Schmalz MJ, Geenen JE. Simple modification of a pancreatic duct stent to prevent proximal migration. Gastrointest Endosc 1993; 39:62.
- Kozarek RA. Pancreatic stents can induce ductal changes consistent with chronic pancreatitis. Gastrointest Endosc 1990; 36:93.
- Smith MT, Sherman S, Ikenberry SO, et al. Alterations in pancreatic ductal morphology following polyethylene pancreatic stent therapy. Gastrointest Endosc 1996; 44:268.
- Sherman S, Alvarez C, Robert M, et al. Polyethylene pancreatic duct stent-induced changes in the normal dog pancreas. Gastrointest Endosc 1993; 39:658.
- Sherman S, Hawes RH, Savides TJ, et al. Stent-induced pancreatic ductal and parenchymal changes: correlation of endoscopic ultrasound with ERCP. Gastrointest Endosc 1996; 44:276.