Editing Pancreas divisum

Failure of the dorsal and ventral ducts to fuse during embryogenesis

* Leads to partial obstruction of the main pancreatic duct at the minor papilla, leading to chronic back pressure
* May cause relapsing acute or chronic pancreatitis

== '''Epidemiology''' ==

* Most common variant of dominant dorsal duct anatomy
* As common as left-handedness - 10%

== '''Pathophysiology''' ==

* Controversial as to whether it actually causes pancreatitis
** Could outflow obstruction at minor papilla be responsible?
** Could there be some other underlying genetic abnormalities? It's associated with a higher prevalence of genetic mutations that predispose to pancreatitis.
** Patients referred for ERCP with pancreatitis have higher incidence of pancreas divisum than expected
** Sphincterotomy or stenting minor papilla does reduce the rate of recurrent pancreatitis
*** If that fails and patients remain symptomatic, or chronic pancreatitis/local complications occur, consider surgery (sphincteroplasty, pancreaticoduodenectomy, duodenum-preserving pancreatic head resection)

== '''Embryology''' ==

* Pancreas formed by fusion of ventral and dorsal buds
* 6th to 7th week: ventral bud rotates clockwise to fuse with the dorsal bud
* Usually, the ventral duct becomes dominant (duct of Wirsung) and duct of Santorini (dorsal duct) is minor.
* If fusion is incomplete, the dorsal duct drains the majority of the pancreas through its SMALLER orifice, and the ventral duct joins with the CBD to drain through the major papilla
* The minor papilla is usually just proximal to the major papilla
* Can be complete or incomplete fusion


== '''Acquired pancreas divisum/pseudodivisum''' ==

* A/w chronic pancreatitis and malignancy
* Total occlusion of ventral duct, causing dorsal duct to assume responsibility for pancreatic exocrine outflow via the minor papilla
* If this diagnosis is questioned but no mass is seen on CT/MRI, EUS should be performed

== '''Presentation''' ==

* Usually asymptomatic - only 5% of patients present with chronic abdo pain, recurrent pancreatitis or chronic pancreatitis
* Rarely develops into severe fibrosing chronic pancreatitis
* Most common presentation is patients with chronic pain intractable to medical management
* Uncommon for acute pancreatitis a/w pancreas divisum to lead to pancreatitis and peripancreatic necrosis - usually self-limiting

== '''Diagnosis''' ==

* MRCP is best modality, and secretin-enhanced MRCP can improve visualisation of congenital pancreaticobiliary malformations
** Indicated with frequent presentations for pancreatitis


== '''Management''' ==

* Aims: improve drainage and resect damaged tissue

=== '''Indications for intervention''' ===

* Endoscopic sphincterotomy
** Pancreatic-type pain in association with obstructive morphology (dilated pancreatic duct or santorinicoele)
** Documented recurrent acute pancreatitis without another clear and reversible cause
*

[[Category:Pancreas]]