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Pancreatic Divisum Workup

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

Imaging Studies

Computed tomography (CT) scanning and ultrasonography of the abdomen are not sensitive enough to aid in diagnosing pancreas divisum. However, they can detect dorsal duct dilatation and other changes of chronic pancreatitis.[11, 12]

Magnetic resonance cholangiopancreatography is being used with increasing frequency as a noninvasive alternative to diagnostic ERCP in the evaluation of the pancreatic duct and various pathologic conditions of the pancreas, including pancreas divisum.[13, 14, 15]

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Procedures

Pancreatography

Pancreas divisum is diagnosed by the aid of pancreatography.

Upon ERCP, the major papilla is often difficult to cannulate, and the duct of Wirsung (ventral duct, see the following image) appears shortened and of small diameter (like a cutoff of the duct) with rapid filling of small accessory ducts.

Cholangiopancreatogram showing small ventral duct Cholangiopancreatogram showing small ventral duct (duct of Wirsung) and normal biliary tree upon cannulation of the major papilla

This should not be confused with a mass lesion such as a malignancy or pancreatic pseudocyst.

At this point, the accessory papilla should be cannulated. A variety of maneuvers have been used to facilitate cannulation. These include simple maneuvers, such as using the long scope position and accessories to include a taper cannula, slick wires, secretagogues, such as Kinevac or secretin, and the application of vital dyes.

This should reveal the duct of Santorini (dorsal duct, as shown in the image below) running the entire length of the pancreas.

Pancreatogram showing the dominant dorsal duct (du Pancreatogram showing the dominant dorsal duct (duct of Santorini) upon cannulation of the minor papilla

In symptomatic patients with recurrent episodes of pancreatitis, ERCP may reveal changes in the pancreatic duct characteristic of chronic pancreatitis.

Endoscopic ultrasonography

Endoscopic ultrasound may be helpful in the identification of pancreas divisum by revealing the absence of a "stalk sign," where the bile duct and pancreatic duct can be seen to run parallel through the pancreatic head.[16]

Manometry

Manometry of the minor papilla is performed infrequently. Symptomatic patients with high basal sphincter pressures might benefit from endoscopic or surgical interventions. However, more studies are needed in this area.

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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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