Pancreas divisum--an underestimated cause of chronic pancreatitis and relapsing episodes of acute pancreatitis?

Recurrent Acute-on-Chronic Pancreatitis in a Chronic Alcoholic With Pancreatic Divisum: A Complex Case

Pancreatic divisum, a rare developmental anomaly of the pancreas, is infrequently observed in young individuals and is a recognized cause of recurrent acute pancreatitis, ultimately progressing to chronic pancreatitis. Chronic alcoholism is a prevalent and significant etiological factor contributing to both recurrent acute pancreatitis and chronic pancreatitis. This case report details the presentation of a 28-year-old patient with a history of chronic alcoholism, exhibiting recurrent acute pancreatitis evolving into chronic pancreatitis. Diagnostic evaluation revealed the presence of pancreatic divisum with associated pancreatic intraductal calculi, a common trigger for pancreatitis. The patient underwent successful management through endoscopic retrograde cholangiopancreatography, pancreatic lithotripsy, and pigtail pancreatic stent placement. This case highlights the complex interplay between chronic alcoholism leading to recurrent acute pancreatitis and pancreatic divisum, a rare congenital anomaly, which is found later in this case, complicating the disease.

Miss rate of pancreas divisum by magnetic resonance cholangiopancreatography in clinical practice

OBJECTIVES

Pancreas divisum is the most common congenital abnormality of the pancreatic anatomy. Magnetic resonance cholangiopancreatography has emerged as a noninvasive method of examining the pancreatic ductal anatomy. We aim to assess the sensitivity of MRCP for pancreas divisum.

METHODS

Patients with pancreas divisum at endoscopic retrograde cholangiopancreatography (ERCP) and who had prior MRCP between January 2001 and February 2006 were identified. Sensitivities were calculated for relevant subgroups with binomial 95% confidence intervals. Fisher exact P values were calculated.

RESULTS

Four hundred five patients had divisum at ERCP; of these, 111 (27%) had undergone MRCP before ERCP. Seventy-two (65%) patients had MRCP at outside centers. Twenty-three of the 72 MRCPs at referring centers correctly reported divisum. In contrast, the sensitivity was higher for the 24 MRCPs without secretin at our institution: 16 (67%). The sensitivity in the secretin-stimulated group was 67% (10/15). However, this was not different from that of MRCP without secretin. Of note, 9 (18%) of the 49 negative outside MRCPs had divisum suspected by the gastroenterologist reviewing the MRCP images before ERCP.

CONCLUSIONS

Pancreas divisum seems to be often missed on MRCP, even when secretin is used. The absence of secretin, use of suboptimal magnetic resonance techniques, and inexperienced pancreatic MRCP examiners are all possible contributing factors.