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Pancreatic Divisum Treatment & Management

  • Author: Rajan Kanth, MD; Chief Editor: BS Anand, MD  more...
 
Updated: Oct 01, 2015
 

Medical Care

Because this anomaly usually is asymptomatic, treatment is offered to symptomatic patients after conducting a complete workup for other causes of pancreatitis and abdominal pain.

Patients with mild symptoms can be managed conservatively. On the other hand, patients with recurrent episodes of pancreatitis or chronic pain may need intervention, which can be performed endoscopically or surgically, to alleviate papillary stenosis. Endoscopic interventions include minor papillotomy (needle-knife sphincterotomy over a stent or pull-type sphincterotomy ), endoscopic stenting, and balloon dilation of minor papilla.

Minor papilla stenosis causing resistance to the flow of pancreatic secretion can lead to increased intraductal pressure. Pathogenesis of pancreatitis and pain in the abdomen is thought to be secondary to increased minor papilla intraductal pressure and, thus, minor papilla ductal decompression is used for management.

Endoscopic minor papilla sphincterotomy can be performed alone or along with stenting.

Sphincterotomy can be performed using a papillotome to make a 4- to 6-mm incision in the 10- to 12-o'clock position or over a stent used as a guide. Patients may need stent exchange, which is usually performed in 3-12 months, and papillary sphincterotomy is repeated. Postendoscopic minor papilla sphincterotomy pancreatitis and hemorrhage are common complications of endotherapy. Papillary restenosis, stent restenosis, and stent migration can occur after endotherapy.

Liao 2009 et al performed a systematic review on endotherapy and surgery for pancreas divisum.[17] Complete or partial pain relief was considered as “response” to treatment. The pooled response rate of endotherapy for acute recurrent pancreatitis was 79.2%, for chronic pancreatitis it was 69%, and for patients with pain related to pancreas divisum, it was 54.4%. The pooled overall response rate to endotherapy was 69.4%, whereas the response rate to surgery was 74.9%. Although the response rate to surgery was slightly higher, the difference was not significant. Thus, endotherapy can be a reasonable first-line treatment option for pain relief in pancreas divisum.

As explained above, acute recurrent pancreatitis had a higher response rate than chronic pancreatitis or chronic abdominal pain associated with pancreas divisum. A study by Rustagi et al also found a similar result.[18] The response rate for acute recurrent pancreatitis was 94%, whereas for chronic pancreatitis and chronic abdominal pain, the response rate, was 57% and 54% respectively.

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Surgical Care

All patients selected for surgical treatment should have confirmation of pancreas divisum by ERCP.

The choice of operation depends on the clinical picture and extent of the disease.[19]

Surgical minor papilla sphincterotomy and sphincteroplasty are discussed as follows:

  • Surgical sphincterotomy series and sphincteroplasty series seem to have similar outcomes.
  • When patient categorization is detailed, meaning recurrent, acute pancreatitis, chronic pain alone, or chronic pancreatitis is present, patients with recurrent attacks of pancreatitis usually respond better to surgical therapy, mirroring the endoscopic therapy series results.
  • In a systematic review, Liao found that the pooled response rate to surgical intervention for acute recurrent pancreatitis, chronic pancreatitis, and chronic abdominal pain was 83.2%, 66.7%, and 51.6%, respectively; the overall response rate to surgery was 74.9%.
  • Some studies have found that patients with chronic pancreatitis have better response to surgical procedure than endotherapy. [20]
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Contributor Information and Disclosures
Author

Rajan Kanth, MD Hospitalist, Ministry Saint Joseph’s Hospital

Rajan Kanth, MD is a member of the following medical societies: American College of Physicians, Society of Hospital Medicine, Nepal Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Mounzer Al Samman, MD Associate Clinical Professor, Department of Internal Medicine, Touro University College of Osteopathic Medicine; Attending Physician, Department of Medicine, NorthBay Health Care and Hospitals; Medical Director, Surgery Center at NorthBay VacaValley

Mounzer Al Samman, MD is a member of the following medical societies: American College of Gastroenterology, American Society for Gastrointestinal Endoscopy, American Gastroenterological Association

Disclosure: Nothing to disclose.

Praveen K Roy, MD, AGAF Chief of Gastroenterology, Presbyterian Hospital; Medical Director of Endoscopy, Presbyterian Medical Group; Adjunct Associate Research Scientist, Lovelace Respiratory Research Institute

Praveen K Roy, MD, AGAF is a member of the following medical societies: American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Additional Contributors

Marco G Patti, MD Professor of Surgery, Director, Center for Esophageal Diseases, University of Chicago Pritzker School of Medicine

Marco G Patti, MD is a member of the following medical societies: American Association for the Advancement of Science, American Surgical Association, American College of Surgeons, American Gastroenterological Association, American Medical Association, Association for Academic Surgery, Pan-Pacific Surgical Association, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, Southwestern Surgical Congress, Western Surgical Association

Disclosure: Nothing to disclose.

Acknowledgements

Mounzer Al Samman, MD Assistant Professor, Department of Internal Medicine, Division of Gastroenterology, Texas Tech University School of Medicine

Mounzer Al Al Samman, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, and American Gastroenterological Association

Disclosure: Nothing to disclose.

Simmy Bank, MD Chair, Professor, Department of Internal Medicine, Division of Gastroenterology, Long Island Jewish Hospital, Albert Einstein College of Medicine

Disclosure: Nothing to disclose.

,

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Cholangiopancreatogram showing small ventral duct (duct of Wirsung) and normal biliary tree upon cannulation of the major papilla
Pancreatogram showing the dominant dorsal duct (duct of Santorini) upon cannulation of the minor papilla
 
 
 
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