Pancreas divisum and its association with choledochal sphincter stenosis. Diagnosis by endoscopic retrograde cholangiopancreatography and endoscopic biliary manometry

Long-term clinical outcomes after endoscopic minor papilla therapy in symptomatic patients with pancreas divisum

OBJECTIVES

To assess the long-term outcomes of endoscopic minor papilla therapy in a spectrum of symptomatic patients with pancreas divisum.

METHODS

Patients with pancreas divisum coded in a prospective database as having had minor papilla endotherapy (July 1997-May 2003, n = 145) were grouped into 3 categories: (1) acute recurrent pancreatitis, (2) chronic pancreatitis, and (3) chronic/recurrent epigastric pain. Telephone follow-up was conducted (78% of patients), including questions regarding interval co-interventions and narcotic use. Primary success was defined as clinical improvement (better or cured on a Likert scale), without needing narcotics, after 1 therapeutic endoscopic retrograde cholangiopancreatography. Fisher exact and Mann-Whitney U tests and multivariate logistic regression were used to identify predictors of success.

RESULTS

Primary success rates in acute recurrent pancreatitis, chronic pancreatitis, and chronic/recurrent epigastric pain were achieved in 53.2%, 18.2%, and 41.4%, respectively; and secondary success rates (<or=2 additional endoscopic retrograde cholangiopancreatographies), 71.0%, 45.5%, and 55.2%, respectively (median follow-up, 43.0 months; range, 14-116 months). Younger age (median age, 46.5 years [no success] vs 58.0 years [success]; P < 0.0001) and chronic pancreatitis (odds ratio, 0.10; 95% confidence interval, 0.03-0.39; P = 0.001) independently predicted a lower chance of success.

CONCLUSIONS

Significant long-term improvement can be achieved with endoscopic therapy in selected patients with pancreas divisum, although many require multiple procedures. Older patients, without chronic pancreatitis, were most likely to respond.

MR pancreatography

Recent innovations in the field of ultrafast MR imaging have increased the robustness of MR cholangiopancreatography (MRCP). Its complete noninvasiveness and flexible physiological approaches in detecting pancreaticobiliary pathologic conditions are gaining the acceptance of many clinicians. The procedure is also safer and more comfortable both for physicians and patients compared with direct pancreatography or cholangiography. Because of its cost effectiveness and safety, optimized MRCP technologies will gradually replace the diagnostic use of endoscopic retrograde cholangiopancreatography (ERCP). It is also notable that MRCP techniques can be used to obtain physiological/dynamic information that ERCP cannot provide. This article addresses recent advances in MRCP from technological and clinical aspects, focusing on its unique features as a hydrographic technique, and also refers to its limitations.

Ventral pancreatitis in a patient with pancreas divisum

Pancreas divisum results in drainage of most pancreatic secretions through the minor papilla via the dorsal duct, and the association of minor papilla stenosis has been implicated as a cause of pancreatitis. Most of the reported cases represent pancreatitis confined to the dorsal part. The authors treated a 10-year-old boy with recurrent pancreatitis that was substantially more severe in the ventral part. The patient was referred with a brief history of abdominal pain and had undergone a laparotomy when segmental ventral pancreatitis had been observed. Severe pancreatitis and acute renal failure developed, which required drainage of the lesser sac and hemodialysis, respectively. After 5 months, he had another episode that subsequently led to a pseudocyst in the ventral part. Endoscopic retrograde cholangiopancreatography via minor papilla showed a normal-caliber dorsal duct communicating with a part of the fine ventral ducts. A normal biliary tree was shown, but no ventral duct was visualized by cannulation to the major papilla of Vater. Dual sphincteroplasties and a cholecystectomy were performed. The minor papilla was stenotic and admitted only the finest lacrimal duct probe. The orifice of the ventral duct could not be observed. Thus it was clarified that the dorsal duct with its stenotic orifice had drained both the dorsal and ventral pancreas. The patient has remained asymptomatic over 36 months postoperatively. Despite their limited experience, the authors believe that (1) this anatomic variant led to ventral pancreatitis, and (2) the sphincteroplasty of the minor papilla was successful.

Evaluation and treatment of the dominant dorsal duct syndrome (pancreas divisum redefined)

The controversial association of pancreatitis and pancreas divisum was studied in 100 patients (77 women, 23 men, median age 35) with episodic acute pancreatitis (49%) or "pancreatic pain" (51%). Seventy-one had classic pancreas divisum (type 1); 23 had only a dorsal duct with an absent Wirsung's duct (type 2); and 6 had a filamentous connection between the two duct systems (type 3). Accessory papilla sphincteroplasty was performed in 88 patients, with a mean follow-up of 53 months. The orifice was stenotic at the mucosal level in 66 patients. Seventy percent of patients have shown improvement: 85% if the accessory papilla was stenotic, compared with 27% if it was not (p less than 0.0001); and 82% with discrete attacks, compared with 56% with chronic pain (p = 0.002). Judged against intraoperative calibration of accessory papilla orifice diameter, ultrasonography with secretin stimulation was 78% sensitive for accessory papilla stenosis, with 3% false-positive results. Ultrasonography with secretin stimulation was the best predictor of surgical success: positive = 92% success (attacks or pain) versus negative = 40% success (64% with attacks; 21% with pain). There have been seven restenoses with six reoperations. We conclude that (1) pancreas divisum is but one variety of pancreatic anatomy characterized by a dominant dorsal duct and dependence on secretion through the accessory papilla; (2) accessory papilla stenosis appears to be a necessary cofactor to produce a morbid state, whether episodic pancreatitis or pancreatic pain; (3) presentation with pancreatitis and a positive result on the ultrasound-secretin test are the best predictors of successful accessory papilla sphincteroplasty.

Isolated ventral pancreatitis in an alcoholic with pancreas divisum

An alcoholic with no history of clinical pancreatitis was found to have pancreas divisum and marked changes of chronic pancreatitis isolated to the ventral pancreas. Pancreas divisum has been suggested to cause recurrent pancreatitis in some patients. Gross and histologic changes of pancreatitis in only the dorsal pancreas of surgically resected specimens from patients with pancreas divisum is thought to support the concept that obstruction at the minor papilla produces dorsal pancreatitis. Alternative explanations for the occurrence of segmental pancreatitis and the possible synergistic role of ethanol and bile are reviewed.

Pancreas divisum: stenosis of the dorsally dominant pancreatic duct. A surgically correctable lesion

Pancreas divisum is a congenital variant of pancreatic duct drainage in which the dorsal duct dominates, most likely due to the failure of the two independent pancreatic ductal systems to fuse embryologically. Although 5 to 10 percent of the population have this congenital variation, few demonstrate symptoms related to their pancreaticobiliary ductal systems. However, patients may present with symptoms referable to this system, and the diagnosis is difficult. In this series, endoscopic retrograde cholangiopancreatography with cannulation and radiographic injection of the dorsal duct demonstrated this abnormality in 30 of 32 patients, and results of morphine-prostigmine testing were positive for symptoms, chemical enzyme elevation, or both in three fourths of the patients tested, but other maneuvers were not as helpful. The surgical approach has been to perform a sphincteroplasty of both the main and accessory ampullas and to excise the gallbladder when it is present. Pathologic study of the gallbladders showed nearly all of them to have been diseased, whereas histologic study of the ampullas was not as conclusive. In general, this condition should be suspected as part of the postcholecystectomy syndrome or in patients who present with idiopathic pancreatitis and whose conditions cannot be identified by all other diagnostic methods. Preoperative screening may be carried out with noninvasive techniques such as the morphine-prostigmine test, or by use of the secretin-stimulated ultrasonographic visualization of the ductal system. The primary tool for making the diagnosis is endoscopic retrograde cholangiopancreatography. The goal of surgical treatment should be the opening of the main and accessory ducts, since this offers the best chance for long-term relief of the patient's symptoms.

Pathophysiologic factors in recurrent acute pancreatitis

No single pathophysiologic factor has been identified as the cause of recurrent acute pancreatitis. A systematic search should be undertaken in every patient to identify one of a myriad of factors that have been shown to play a part in causing this distressing illness. The abuse of alcohol remains the likeliest cause, and further research may reveal an inborn error of metabolism that jeopardizes some people. Biliary tract disease, gallstones, choledochal cyst, papillary stenosis, and duodenal diverticula show a clear relationship. Metabolic disorders such as hypercalcemia, hyperlipidemia, and hyperparathyroidism remain suspect. Systemic illnesses such as systemic lupus erythematosus and cystic fibrosis must be considered. Development anomalies such as pancreas divisum may precipitate acute pancreatitis through aberrant anatomic structures. Cancer must always be disproved. Not yet firmly established but worthy of thorough investigation are uncommon causes, such as the ingestion of certain drugs or combinations of drugs and trauma, either recent or past. Pancreatitis remains frightening for those with the disease and puzzling and frustrating for the medical people who treat it. A careful history and investigation in accordance with a systematic diagnostic plan that includes many disparate factors will lead to identification of the cause in the majority of patients.