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Sitaraman LM, Sachdev AH, Gonda TA, Sethi A, Poneros JM, Gress FG. The Utility of Endoscopic Ultrasound in Patients with Isolated Elevations in Serum Amylase and/or Lipase. Clin Endosc 2019; 52:175-181. [PMID: 30646674 PMCID: PMC6453845 DOI: 10.5946/ce.2018.110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 11/02/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND/AIMS The aim of this study was to describe the diagnostic yield of endoscopic ultrasound (EUS) in patients with isolated elevated levels of amylase and/or lipase. METHODS A retrospective chart review was conducted at a large academic medical center from 2000 to 2016. Patients were selected based on having elevated amylase, lipase, or both, but without a diagnosis of pancreatitis or known pancreatobiliary disease. Patients were excluded if they had abnormal liver function tests or abnormal imaging of the pancreas. RESULTS Of 299 EUS procedures performed, 38 met inclusion criteria. Symptoms were present in 31 patients, most frequently abdominal pain (87%). In 20 patients (53%), initial EUS most commonly found chronic pancreatitis (n=7; 18%), sludge (5; 13%), or new diagnosis of pancreas divisum (3; 8%). In the asymptomatic patients (7), 3 had a finding on EUS, most importantly sludge (2), stone (1), and pancreas divisum (1). No patients were diagnosed with a mass or pancreatic cyst. During the follow up period, 6 patients (22%) had cholecystectomy. CONCLUSION In our study of patients with isolated elevations in amylase and/or lipase without acute pancreatitis who underwent EUS, approximately 50% had a pancreatobiliary finding, most commonly chronic pancreatitis or biliary sludge.
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Affiliation(s)
- Lalitha M Sitaraman
- Division of Digestive Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Amit H Sachdev
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, NY, USA
| | - Tamas A Gonda
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, NY, USA
| | - Amrita Sethi
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, NY, USA
| | - John M Poneros
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, NY, USA
| | - Frank G Gress
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, NY, USA
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Somani P, Navaneethan U. Role of ERCP in Patients With Idiopathic Recurrent Acute Pancreatitis. ACTA ACUST UNITED AC 2016; 14:327-39. [PMID: 27371265 DOI: 10.1007/s11938-016-0096-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OPINION STATEMENT Recurrent acute pancreatitis (RAP) is defined based on the occurrence of two or more episodes of acute pancreatitis. RAP is differentiated from chronic pancreatitis based on the presence of a normal morphological appearance of the pancreas between episodes. RAP can be due to a variety of etiologies including common bile duct stones or sludge, sphincter of Oddi dysfunction (SOD), pancreas divisum (PD), anomalous pancreaticobiliary junction, genetic mutations, and alcohol related. In approximately 30 % of patients, the etiology of RAP is unclear and the term "idiopathic" is used. Endoscopic retrograde cholangiopancreatography (ERCP) can be utilized in both the diagnosis and the initial management of RAP, but it has known limitations and risks. Since gallbladder sludge and SOD account for most cases with RAP, cholecystectomy and, eventually, endoscopic biliary and/or pancreatic sphincterotomy are performed as a part of management. In patients with PD-associated RAP, data from uncontrolled and primarily retrospective studies point toward a benefit from minor papillary endoscopic intervention. However, given the lack of quality data from prospective randomized controlled trials (RCTs), endoscopic management in such patients remains an individualized decision, and RCTs are needed to ascertain its true long-term benefit. Future studies to investigate the role of endoscopic therapy in preventing progression to chronic pancreatitis are needed.
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Affiliation(s)
- Piyush Somani
- Center for Interventional Endoscopy, University of Central Florida College of Medicine, Florida Hospital, 601 E Rollins Street, Orlando, FL, 32803, USA
| | - Udayakumar Navaneethan
- Center for Interventional Endoscopy, University of Central Florida College of Medicine, Florida Hospital, 601 E Rollins Street, Orlando, FL, 32803, USA.
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Riff BP, Chandrasekhara V. The Role of Endoscopic Retrograde Cholangiopancreatography in Management of Pancreatic Diseases. Gastroenterol Clin North Am 2016; 45:45-65. [PMID: 26895680 DOI: 10.1016/j.gtc.2015.10.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Endoscopic retrograde cholangiopancreatography is an effective platform for a variety of therapies in the management of benign and malignant disease of the pancreas. Over the last 50 years, endotherapy has evolved into the first-line therapy in the majority of acute and chronic inflammatory diseases of the pancreas. As this field advances, it is important that gastroenterologists maintain an adequate knowledge of procedure indication, maintain sufficient procedure volume to handle complex pancreatic endotherapy, and understand alternate approaches to pancreatic diseases including medical management, therapy guided by endoscopic ultrasonography, and surgical options.
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Affiliation(s)
- Brian P Riff
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1069, New York, NY 10029, USA
| | - Vinay Chandrasekhara
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Boulevard, Perelman Center for Advanced Medicine South Pavilion, 7th Floor, Philadelphia, PA 19104, USA.
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Gurram KC, Czapla A, Thakkar S. Acute pancreatitis: pancreas divisum with ventral duct intraductal papillary mucinous neoplasms. BMJ Case Rep 2014; 2014:bcr-2014-205322. [PMID: 25293684 DOI: 10.1136/bcr-2014-205322] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Acute recurrent pancreatitis occurs rarely in individuals with pancreas divisum. A 39-year-old woman with no significant history presented with pancreatitis. CT scan and MRI suggested acute on chronic pancreatitis with calcifications and pancreatic divisum. An endoscopic ultrasound demonstrated complete pancreas divisum. A large calcification measuring 12 mm × 6 mm was seen in the head of the pancreas with associated dilation of the ventral pancreatic duct. Fine-needle aspiration of the dilated ventral pancreatic duct showed an amylase level of 36,923 U/L and a carcinoembryonic antigen of 194. A ventral duct intraductal papillary mucinous neoplasm was suspected and a pancreaticoduodenectomy procedure was recommended. After the procedure, pathology demonstrated an intraductal papillary lesion in the main duct with moderate dysplasia. A pancreatic intraepithelial neoplasia, grade 2 was also present. Margins of resection were clear. This case represents the importance of assessing for secondary causes of pancreatitis in pancreas divisum.
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Affiliation(s)
- Krishna C Gurram
- Department of Gastroenterology, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Agata Czapla
- Departement of Pathology, Allegheny Health Network AGH, Pittsburgh, Pennsylvania, USA
| | - Shyam Thakkar
- Department of Gastroenterology, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
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Asayama Y, Fang W, Stolpen A, Kuehn D. Detectability of pancreas divisum in patients with acute pancreatitis on multi-detector row computed tomography. Emerg Radiol 2011; 19:121-5. [PMID: 22167339 DOI: 10.1007/s10140-011-1008-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Accepted: 11/28/2011] [Indexed: 12/22/2022]
Abstract
The purpose of this study was to retrospectively assess the diagnostic performance of multi-detector row computed tomography (MDCT) in an evaluation of pancreas divisum using endoscopic retrograde pancreatography (ERP) as the reference standard. We analyzed 41 consecutive patients (14 cases of pancreas divisum and 27 cases of standard anatomy) who had undergone both MDCT and ERP for the evaluation of clinically diagnosed acute pancreatitis between November 2004 and June 2007. The CT reconstruction thickness and interval were both 3 mm. Two radiologists independently reviewed CT data, and the diagnostic confidence in determining the pancreatic ductal anatomy was scored using a five-point scale. CT detectability was correlated with the severity of pancreatitis and the degree of pancreatic necrosis based on the Balthazar index. With consensus, 16 of 41 cases (39.0%) were evaluated as indeterminate. Ductal anatomy was correctly diagnosed in 23 of 41 cases (56.1%). Eight of 14 cases (57.1%) were correctly diagnosed as pancreas divisum. Standard anatomy was identified in 15 of 27 cases (55.6%). The inter-observer agreement was substantial (κ = 0.71). Grade B or more pancreatitis and the presence of pancreatic necrosis significantly influenced the evaluation of ductal anatomy (p = 0.01 and p < 0.01, respectively). Pancreas divisum was correctly diagnosed in the case of grade A acute pancreatitis. The CT detectability of pancreas divisum in patients with grade B or more pancreatitis is still relatively low even in the MDCT era.
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Affiliation(s)
- Yoshiki Asayama
- Department of Radiology, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA 52242, USA.
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Herszényi L, Szmola R, Tulassay Z. [Clinical importance of pancreas divisum]. Orv Hetil 2011; 152:1764-71. [PMID: 21997581 DOI: 10.1556/oh.2011.29231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Pancreas divisum, the most common congenital pancreatic anomaly, is associated with three main duct abnormalities: type I, with total failure of fusion; type II, with dorsal duct dominant drainage; and type III, incomplete divisum where a small communication branch is present. Three clinical conditions are associated with pancreas divisum: (1) acute recurrent pancreatitis; (2) chronic pancreatitis with the chronic inflammation in the dorsal bed; (3) abdominal "pancreatic-type" obstructive pain. Endoscopic retrograde cholangiopancreatography is the primary method for diagnosing pancreas divisum, but magnetic resonance cholangiopancreatography is becoming a first choice for non-invasive evaluation. Pancreas divisum per se does not require medical intervention. Patients who experience mild episodic acute pancreatitis should be managed medically. Surgical or endoscopic interventions relieve the obstruction by improving dorsal duct drainage via the minor papilla.
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Affiliation(s)
- László Herszényi
- Semmelweis Egyetem, Általános Orvostudományi Kar II. Belgyógyászati Klinika, Budapest.
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Abstract
We review important new clinical observations in pancreas divisum (PD) made since 2007. PD is common and has the same prevalence in the general population and idiopathic pancreatitis (IP). Up to 53% of patients with PD and IP have underlying idiopathic chronic pancreatitis (CP), and in rigorous prospective clinical follow-up and/or natural history studies, many with idiopathic recurrent acute pancreatitis (IRAP) have idiopathic CP. According to retrospective studies, PD does not modify the natural course of nonalcoholic or alcoholic CP. CFTR and/or SPINK1 gene mutations associate with IP (idiopathic CP and IRAP) independently of the presence of PD. More than one third of patients with pancreatitis or presumed pancreaticobiliary pain respond to placebo. Authors of uncontrolled studies report a significant symptomatic response to surgery and endotherapy in patients with IP and PD, but the response remains unproven and is largely limited to those with IRAP and not idiopathic CP or chronic pain.
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Affiliation(s)
- Matthew J DiMagno
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Michigan Medical School, 1150 West Medical Center Drive, Room 6520 MSRB I, Ann Arbor, MI 48109-0682, USA.
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Affiliation(s)
- Ami P Shah
- Department of Pediatrics, Children's Hospital of Michigan, Detroit, 48201, USA.
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10
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Park JB, Seo JH, Park JY, Park SW, Song SY, Chung JB, Bang S. [Endoscopic treatment of a pediatric patient with acute pancreatitis caused by anomalous union of pancreaticobiliary duct combined with incomplete pancreatic divisum]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2010; 54:333-6. [PMID: 19934615 DOI: 10.4166/kjg.2009.54.5.333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The most common causes of acute pancreatitis are microlithiasis and alcohol. In pediatrics, anomalies in pancreaticobiliary system should be considered as possible causes. Among many anomalies, pancreas divisum associated with anomalous pancreaticobiliary ductal union (APBDU) is very rare. APBDU is associated with acute pancreatitis, choledochal cyst, and gallbladder cancer. Pancreas divisum is also a well known cause of acute recurrent pancreatitis. In adult cases with such conditions, the role of endoscopic management including sphincterotomy or stenting through the Santorini duct is well documented. However, it is still controversial to perform endoscopic retrograde cholangiopancreatography in pediatrics. Herein, we experienced a case of 4 year 7 month old female patient suffered from recurrent attacks of acute pancreatitis, which were caused by APBDU and incomplete pancreas divisum. She was treated by endoscopic sphincterectomy of both openings to the Santorinis and Wirsungs ducts. Thus, we report this interesting case with literature review.
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Affiliation(s)
- Jun Beom Park
- Division of Gastroenterology, Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
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Wang W, Liao Z, Li ZS, Shi XG, Wang LW, Liu F, Wu RP, Zheng JM. Chronic pancreatitis in Chinese children: etiology, clinical presentation and imaging diagnosis. J Gastroenterol Hepatol 2009; 24:1862-8. [PMID: 19793170 DOI: 10.1111/j.1440-1746.2009.05967.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND AIMS There is a paucity of literature regarding the clinical profile of chronic pancreatitis (CP) in children. The aims of this retrospective study were to determine the etiology and clinical presentation, and to present our experience in diagnosing CP in children in China. METHODS Clinical data of children who were treated for CP at Changhai Hospital from January 1997 to August 2006 were reviewed. RESULTS A total of 427 CP patients presented to our center. There were 42 (9.8%) children with CP, including 21 males and 21 females, with a mean age of 11.7 years at the first onset. The main etiological factor was idiopathic (73.8%). Of the patients, 78.5% had episodes of mild to moderate abdominal pain and 54.8% had multiple (> or = 4) episodes. The mean duration of symptoms prior to the diagnosis was 41.6 months and a definite diagnosis was not made until 2 years later in 57.1% of these patients. The positive rates of ultrasound (US), computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) (or magnetic resonance imaging [MRI]) for detecting ductal changes and intraductal stones or pancreatic calcification were 51.4% and 45.4%, 71.4% and 87.5%, 80.0% and 61.5%, respectively. CONCLUSION The main etiological factor of Chinese children with CP is idiopathic. The main symptom in these patients is multiple episodes of mild to moderate abdominal pain, which often lead to a delay in the definite diagnosis. CT and MRCP (or MRI) should be used as the first investigation in the evaluation of these cases.
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Affiliation(s)
- Wei Wang
- Chronic Pancreatitis Study Group, Department of Gastroenterology, Changhai Hospital, The Second Military Medicine University, Shanghai, China
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12
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Abstract
Recent advances in understanding of pancreatitis and advances in technology have uncovered the veils of idiopathic pancreatitis to a point where a thorough history and judicious use of diagnostic techniques elucidate the cause in over 80% of cases. This review examines the multitude of etiologies of what were once labeled idiopathic pancreatitis and provides the current evidence on each. This review begins with a background review of the current epidemiology of idiopathic pancreatitis prior to discussion of various etiologies. Etiologies of medications, infections, toxins, autoimmune disorders, vascular causes, and anatomic and functional causes are explored in detail. We conclude with management of true idiopathic pancreatitis and a summary of the various etiologic agents. Throughout this review, areas of controversies are highlighted.
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13
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Affiliation(s)
- Fumitake TOKI
- Department of Medicine, Institute of Gastroenterology, Tokyo Women's Medical College, Tokyo, Japan
| | - Tadahiko KOZU
- Department of Medicine, Institute of Gastroenterology, Tokyo Women's Medical College, Tokyo, Japan
| | - Kenji YOSHIDA
- Department of Medicine, Institute of Gastroenterology, Tokyo Women's Medical College, Tokyo, Japan
| | - Takayoshi NISHINO
- Department of Medicine, Institute of Gastroenterology, Tokyo Women's Medical College, Tokyo, Japan
| | - Hiroyuki TADOKORO
- Department of Medicine, Institute of Gastroenterology, Tokyo Women's Medical College, Tokyo, Japan
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Dray X, Fajac I, Bienvenu T, Chryssostalis A, Sogni P, Hubert D. Association of pancreas divisum and recurrent acute pancreatitis with the IVS8-5T-12TG allele of the CFTR gene and CFTR dysfunction. Pancreas 2007; 35:90-3. [PMID: 17575549 DOI: 10.1097/mpa.0b013e318054771f] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Pancreas divisum (PD) occurs in approximately 10% of individuals. Although a minority of patients with PD develop acute pancreatitis (AP), PD is found in up to 25% of patients with unexplained AP. Mild mutations or variants of the cystic fibrosis transmembrane conductance regulator (CFTR) gene, including the IVS8-5T variant, are associated with idiopathic pancreatitis, but their relationship with PD is unknown. We hypothesized for such association. METHODS Case of 2 patients with PD, recurrent AP, and CFTR-related disease are reported. RESULTS Both patients had similar clinical patterns (young female adults, nonsevere onsets of AP, mild upper airway manifestations, no major clinical criteria for cystic fibrosis). They had 2 mutations or variants of the CFTR gene (including the IVS8-5T-12TG allele) and mild abnormalities of the CFTR function (increased sweat chloride concentrations in one patient, normal basal but low responses to low-chloride and/or isoproterenol solutions on nasal potential difference). CONCLUSIONS These observations suggest that impaired epithelial ion transport due to mild CFTR genotype (namely, IVS8-5T-TG12) might be involved as a triggering factor in acute onsets of pancreatitis in PD, possibly through abnormal pancreatic fluid secretion. Further studies on CFTR mutations and abnormal nasal airway ion transport in patients with PD, either with or without recurrent AP, should be conducted.
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Affiliation(s)
- Xavier Dray
- Département de Pathologie Digestive, APHP, Hôpital Lariboisière, Paris, France
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Fogel EL, Toth TG, Lehman GA, DiMagno MJ, DiMagno EP. Does endoscopic therapy favorably affect the outcome of patients who have recurrent acute pancreatitis and pancreas divisum? Pancreas 2007; 34:21-45. [PMID: 17198181 DOI: 10.1097/mpa.0b013e31802ce068] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Evan L Fogel
- Division of Gastroenterology/Hepatology, Indiana University Medical Center, Indiana, IN, USA
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Bang S, Suh JH, Park BK, Park SW, Song SY, Chung JB. The relationship of anatomic variation of pancreatic ductal system and pancreaticobiliary diseases. Yonsei Med J 2006; 47:243-8. [PMID: 16642555 PMCID: PMC2687635 DOI: 10.3349/ymj.2006.47.2.243] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
The aims of this study were to identify the morphological diversities and anatomical variations of pancreatic ductal system and to define the relationships between pancreatic ductal systems, pancreaticobiliary diseases, and procedure- related complications, including post-ERCP pancreatitis. This study included 582 patients in whom both pancreatic duct (PD) and common bile duct were clearly visible by ERCP. PD systems were categorized into four types according to the relationship between common bile duct and PD. In types A and B, Wirsung duct formed the main PD. In type C, Wirsung duct did not form the main PD. If PD system did not fall into any of these three types, it was categorized as type D. The distribution of types among pancreatic ducts examined was as follows: type A: 491 cases (84.4%), type B: 56 cases (9.6%), type C: 20 cases (3.4%), and type D: 15 cases (2.6%). The anomalous anatomic variations of PD systems were divided into migration, fusion, and duplication anomalies. PD anomalies were noted in 51 patients, of which 19 (3.3%) were fusion anomalies (12 complete pancreas divisum, 7 incomplete pancreas divisum), and 32 (5.5%) were duplication anomalies (5 number variations, 27 form variations). No significant relationships between various PD morphologies and pancreaticobiliary diseases were found. However, post- ERCP hyperamylasemia was more frequently found in types C (41.7%), D (50%) and A (19.8%) than in type B (9.4%). In summary, whether Wirsung duct forms the main PD and the presence or absence of the opening of the Santorini duct are both important factors in determining the development of pancreatitis and hyperamylasemia after ERCP.
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Affiliation(s)
- Seungmin Bang
- Division of Gastroenterology, Institute of Gastroenterology, Departments of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Hoon Suh
- Division of Gastroenterology, Institute of Gastroenterology, Departments of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Byung Kyu Park
- Division of Gastroenterology, Institute of Gastroenterology, Departments of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Woo Park
- Division of Gastroenterology, Institute of Gastroenterology, Departments of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Si Young Song
- Division of Gastroenterology, Institute of Gastroenterology, Departments of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Bock Chung
- Division of Gastroenterology, Institute of Gastroenterology, Departments of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
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Itoh S, Takada A, Satake H, Ota T, Ishigaki T. Diagnostic Value of Multislice Computed Tomography for Pancreas Divisum. J Comput Assist Tomogr 2005; 29:452-60. [PMID: 16012299 DOI: 10.1097/01.rct.0000164670.88519.e5] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To assess the capabilities of high-resolution oblique coronal reconstruction images obtained by multislice computed tomography (CT) in diagnosing pancreas divisum. METHODS This study included 11 patients with and 53 without pancreas divisum confirmed by direct cholangiopancreatography. Two blinded readers retrospectively interpreted oblique coronal reconstruction images with 0.5-mm continuous slices generated from isotropic or nearly isotropic pancreatic phase images with the scrolling mode and assessed the continuity of the ventral pancreatic duct, dorsal pancreatic duct, and main pancreatic duct in the body. The results were correlated with the findings of direct cholangiopancreatography. Other abnormal findings of the pancreatobiliary region on CT were also recorded in patients with pancreas divisum. RESULTS The sensitivity and specificity of CT for diagnosing pancreas divisum were 100% and 89%, respectively. Computed tomography demonstrated all associated pancreatobiliary diseases. CONCLUSION High-resolution oblique coronal reconstruction images allow us to make a diagnosis of pancreas divisum by depicting the continuity of the pancreatic ducts.
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Affiliation(s)
- Shigeki Itoh
- Department of Technical Radiology, Nagoya University School of Health Sciences, Nagoya 461-8673, Japan.
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Affiliation(s)
- Steven D Klein
- Department of Medicine, Emory University, Atlanta, GA 30322, USA
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Kalady MF, Peterson B, Baillie J, Onaitis MW, Abdul-Wahab OI, Howden JK, Jowell PS, Branch MS, Clary BM, Pappas TN, Tyler DS. Pancreatic duct strictures: identifying risk of malignancy. Ann Surg Oncol 2004; 11:581-8. [PMID: 15150064 DOI: 10.1245/aso.2004.03.070] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND This study aimed to define PDS characteristics that predict malignancy and would thus invoke further diagnostic evaluation or aggressive treatment. METHODS 355 cases of PDS were diagnosed by ERCP during a 7-year period at a single institution. A retrospective review identified clinical/demographic patient data and ERCP results. RESULTS 218 (61%) patients with a PDS were found to have an isolated PDS. Twelve percent of isolated PDS and 79% of CBD stricture-associated PDS were malignant. The sensitivity and specificity for the double duct sign for malignancy were 77% and 80% respectively, and the positive predictive value was 65%. Predictors of malignancy were statistically similar for both isolated PDS and those associated with a CBD stricture. Univariate predictors of malignancy included stricture location in the pancreatic head/neck, jaundice, and patient age. Predictors of benign disease included a history of pancreatitis, the presence of multiple strictures, pancreatic duct stones, pseudocyst, pancreas divisum anatomy, irregular side branches, and irregular pancreatic duct morphology. Less than 1% of patients with either pancreas divisum anatomy, pancreatic duct stones, or pancreatic pseudocyst had malignancy. Using malignancy as the dependent variable, multivariate factors included in the final prognostic equation were history of pancreatitis (odds ratio 0.009 with history of pancreatitis), stricture location in the head or neck (odds ratio 42) and irregular pancreatic duct side branches (odds ratio 0.05 with irregular branches). CONCLUSIONS This study demonstrates that certain characteristics of PDS can predict the subset of patients who have an increased risk of cancer.
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Affiliation(s)
- Matthew F Kalady
- Department of Surgery, Duke University Medical Center, Box 3118, Durham, NC 27710, USA
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Abstract
Acute pancreatitis is caused by acute or chronic alcohol intake or choledocholithiasis in approximately 80% of cases. In the absence of alcohol abuse or gallstones, a variety of established and putative factors must be considered, any of which can cause a single or recurrent attacks of acute pancreatitis. When the underlying cause eludes detection following an initial thorough search and leads to a second attack, the term idiopathic acute recurrent pancreatitis (IARP) is applied. This article discusses IARP and its work-up.
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Affiliation(s)
- Asif Khalid
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, PA 15213, USA
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Abstract
Pancreas divisum is the most common congenital anomaly of the pancreas and has been reported to be an infrequent cause of acute and recurrent pancreatitis. The authors herein report a 4-year-old child with acute pancreatitis associated with pancreas divisum. Coexistent ascariasis initially suggested a diagnosis of pancreatic ascariasis.
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Affiliation(s)
- Devendra Mishra
- Department of Pediatrics, Dr. Ram Manohar Lohia Hospital, New Delhi, India.
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Matos C, Metens T, Devière J, Delhaye M, Le Moine O, Cremer M. Pancreas divisum: evaluation with secretin-enhanced magnetic resonance cholangiopancreatography. Gastrointest Endosc 2001; 53:728-33. [PMID: 11375579 DOI: 10.1067/mge.2001.114784] [Citation(s) in RCA: 99] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The clinical significance of pancreas divisum (PD) remains controversial. Secretin-enhanced magnetic resonance cholangiopancreatography (S-MRCP) is a noninvasive diagnostic procedure that relies on the dynamic response of the main pancreatic duct (MPD) to secretin stimulation. The aim of this study was to determine the frequency of PD and to analyze the dynamic changes of the MPD by using S-MRCP in patients referred for suspected pancreatic diseases before ERCP. METHODS MRCP was obtained before and at 30-second intervals over 10 minutes after secretin stimulation in consecutive patients with idiopathic acute pancreatitis (n = 67), persistent hydrolasemia (n = 42), recurrent abdominal pain thought to be of pancreatic origin (n = 48), severe chronic pancreatitis (n = 68), and in a control group (n = 54). RESULTS Thirty patients (10.8%) had a PD at S-MRCP. Secretin stimulation improved the detection of PD in 23% (7/30). The frequency of PD was not significantly different (p > 0.2) between these groups. The occurrence of an abnormal response at S-MRCP (persistent dilatation of the MPD) did not significantly differ in patients with or without PD (p > 0.4). CONCLUSION The frequency of PD did not differ between groups, and the dynamic changes of the MPD during S-MRCP were similar in patients with and without PD.
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Affiliation(s)
- C Matos
- Department of Radiology, Division of Magnetic Resonance, and Department of Gastroenterology, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
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Abstract
Pancreas divisum is a common congenital variation that can be associated with pancreatic disease. Symptomatic patients with divisum must be classified according to clinical presentation and morphologic findings. Response to endoscopic therapy is best in patients with ARP, of whom 75% benefit. Results in patients with chronic pancreatitis and pain but without objective pancreatitis are mixed, and patients should be carefully selected.
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Affiliation(s)
- S A Cohen
- Columbia University College of Physicians and Surgeons, and Division of Gastroenterology, St. Luke's-Roosevelt Hospital Center, New York, New York, USA
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24
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Matar LD, Frazer C. Two-tone pancreas on T1-weighted images: correlation with abnormalities on magnetic resonance pancreatography. AUSTRALASIAN RADIOLOGY 2001; 45:58-61. [PMID: 11259975 DOI: 10.1046/j.1440-1673.2001.00876.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Abstract
Two patients are presented in whom geographical alteration in signal between areas of normal and abnormal pancreatic tissue on T1-weighted magnetic resonance images of the pancreas was observed. This alteration in signal intensity produced a 'two-tone' pattern; magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) in both patients revealed altered pancreatic duct drainage. It is believed that the 'two-tone' pancreas effect on T1-weighted images of the abdomen, may indicate aberrant duct drainage and that MRCP is an ideal means of further evaluation.
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Affiliation(s)
- L D Matar
- Department of Radiology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
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25
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García-Vila JH, Jornet J, Redondo M, Díaz C, Salvador-Sanchis JL. Páncreas divisum: tratamiento combinado por cirugía abierta y radiología intervencionista. RADIOLOGIA 2001. [DOI: 10.1016/s0033-8338(01)76978-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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26
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Abstract
Acute pancreatitis is a disorder that has numerous causes and an obscure pathogenesis. Bile duct stones and alcohol abuse together account for about 80% of acute pancreatitis. Most episodes of biliary pancreatitis are associated with transient impaction of the stone in the ampulla (that causes obstruction of the pancreatic duct, with ductal hypertension) or passage of the stone though and into the duodenum. Other causes of acute pancreatitis are various toxins, drugs, other obstructive causes (such as malignancy or fibrotic sphincter of Oddi), metabolic abnormalities, trauma, ischemia, infection, autoimmune diseases, etc. In 10% of cases of acute pancreatitis, no underlying cause can be identified; this is idiopathic pancreatitis. Occult biliary microlithiasis may be the cause of two thirds of the cases of "idiopathic" acute pancreatitis. Intra-acinar activation of trypsinogen plays a central role in the pathogenesis of acute pancreatitis, resulting in subsequent activation of other proteases causing the subsequent cell damage. Ischemia/reperfusion injury is increasingly recognized as a common and important mechanism in the pathogenesis of acute pancreatitis and especially in the progression from mild edematous to severe necrotizing form. Increased intracellular calcium concentration also mediates acinar cell damage. Oxygen-derived free radicals and many cytokines (e.g., interleukin [IL]-1, IL-6, IL-8, tumor necrosis factor-alpha, platelet activating factor) are considered to be principal mediators in the transformation of acute pancreatitis from a local inflammatory process into a multiorgan illness.
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Affiliation(s)
- G H Sakorafas
- Department of Surgery, 251 Helleni Air Force, General Hospital, Athens, Greece.
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27
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Eisendrath P, Delhaye M, Matos C, Baize M, Cremer M, Devière J. Prevalence and clinical evolution of isolated ventral pancreatitis in alcoholic chronic pancreatitis. Gastrointest Endosc 2000; 51:45-50. [PMID: 10625795 DOI: 10.1016/s0016-5107(00)70386-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The role of pancreas divisum in chronic pancreatitis is controversial. Ductal changes limited to the pancreatic ventral duct (isolated ventral pancreatitis) have only been described as isolated case reports. METHODS In a cohort of 542 patients with chronic pancreatitis we determined the frequency of ventral chronic pancreatitis among patients with pancreas divisum and analyzed the clinical presentation of 10 patients with isolated ventral alcohol-induced pancreatitis compared with 10 patients with isolated dorsal alcohol-induced pancreatitis and 30 patients with chronic pancreatitis and without pancreas divisum. Magnetic resonance pancreatography under secretin stimulation was used to evaluate the status of the dorsal pancreatic duct in some patients during follow-up. RESULTS We identified 62 (11.4%) patients with pancreas divisum and 16 (2.9%) patients with incomplete pancreas divisum. The ventral duct was affected by chronic pancreatitis in 74% of these patients. Isolated ventral or dorsal duct alterations were identified in 14% and 26%, respectively, of patients with pancreas divisum. Patients with isolated ventral pancreatitis had pain symptoms similar to those of the two other groups but had no endocrine or exocrine insufficiency on initial presentation. After a mean follow-up of 44 months, 83% of patients studied with isolated ventral pancreatitis developed alterations of the dorsal ductal part of the gland. CONCLUSION We conclude that isolated ventral alcohol-induced pancreatitis is one of the first manifestations of generalized pancreatic disease where the anatomic factor of pancreas divisum plays only a marginal role.
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Affiliation(s)
- P Eisendrath
- Department of Gastroenterology, Erasme Hospital, Free University of Brussels, Bruxelles, Belgium
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28
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Wehrmann T, Schmitt T, Seifert H. Endoscopic botulinum toxin injection into the minor papilla for treatment of idiopathic recurrent pancreatitis in patients with pancreas divisum. Gastrointest Endosc 1999; 50:545-8. [PMID: 10502179 DOI: 10.1016/s0016-5107(99)70081-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND In some patients with pancreas divisum, obstruction to the flow of pancreatic juice into the duodenum is the presumptive cause of acute recurrent pancreatitis. However, identification of those patients who may benefit from minor papilla sphincterotomy or stent placement is difficult. METHODS Five patients with acute recurrent pancreatitis and pancreas divisum were therefore treated by endoscopic injection of 50 units of botulinum toxin into the minor papilla in an outpatient setting. RESULTS Botulinum toxin injection was successfully performed on six occasions in 5 patients and no adverse effects were noted. Two patients relapsed after 9 and 10 months, respectively, but had definite relief of symptoms after needle-knife sphincterotomy. One patient relapsed 7 months after botulinum toxin injection but became symptom free again after a second botulinum toxin injection. Another patient is still in clinical remission 4 months after botulinum toxin administration, and 1 patient did not respond to either botulinum toxin administration or to sphincterotomy and stent placement. CONCLUSIONS Endoscopic injection of botulinum toxin into the minor papilla in patients with pancreas divisum and acute recurrent pancreatitis is a safe procedure that is easy to perform and provides short-term relief in some patients. Response to botulinum toxin injection may predict whether patients with pancreas divisum and acute recurrent pancreatitis will benefit from other forms of endoscopic therapy.
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Affiliation(s)
- T Wehrmann
- Department of Internal Medicine II, J. W. Goethe-University Hospital, Frankfurt am Main, Germany
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29
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Jakobs R, Riemann JF. The role of endoscopy in acute recurrent and chronic pancreatitis and pancreatic cancer. Gastroenterol Clin North Am 1999; 28:783-800, xii. [PMID: 10503150 DOI: 10.1016/s0889-8553(05)70087-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
Endoscopy plays an important role in the diagnosis and treatment of acute and chronic pancreatitis as well as pancreatic cancer. Sphincterotomy and stone removal in biliary pancreatitis, stone extraction and drainage in chronic pancreatitis, and stent implantation in pancreatic cancer are the predominant procedures. With endoscopy, minimal invasive techniques are at hand to solve urgent and long term problems.
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Affiliation(s)
- R Jakobs
- Department of Gastroenterology, Klinikum der Stadt Ludwigshafen gGmbH, Academic Teaching Hospital, University of Mainz, Germany
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30
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Abstract
Pancreas divisum has been claimed to be a harmless congenital variant or to occasionally cause acute relapsing pancreatitis (ARP), chronic pancreatitis (CP), or a chronic abdominal pain (CAP) syndrome. Both surgical and endoscopic approaches to accessory papilla decompression have been promulgated and widely disparate results reported in the literature. We retrospectively reviewed a five-year experience with dorsal pancreatic duct decompression at our institution utilizing a variety of endotherapeutic techniques. Data collected included procedural complications; patient interpretation of pre- and posttherapy pain, frequency, and intensity graded on an analog pain scale; frequency of hospitalization; and patient perception of "global" improvement to endotherapy. At a mean follow-up of 20 months, there was a statistically significant decrease in pancreatitis incidence in 15 patients with ARP (P = 0.016) and 19 patients with CP (P = 0.025). The frequency and intensity of chronic pain was also significantly improved (P < 0.001) in the latter group. In contrast, only one of five patients with CAP and normal dorsal pancreatography and secretin tests experienced global improvement, and there was no improvement utilizing an analog pain scale (P = 0.262) in the group as a whole. There was a 20% incidence of mild procedure or subsequent stent-related pancreatitis and an 11.5% accessory papilla restenosis rate. It is concluded that a subset of carefully selected patients with pancreas divisum may respond to endotherapy but that long-term follow-up will be required to define its ultimate place in the management of symptomatic patients with this anomaly.
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Affiliation(s)
- R A Kozarek
- Section of Gastroenterology, Virginia Mason Medical Center, Seattle, Washington, USA
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31
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Uomo G, Manes G, D'Anna L, Laccetti M, Di Gaeta S, Rabitti PG. Fusion and duplication variants of pancreatic duct system. Clinical and pancreatographic evaluation. INTERNATIONAL JOURNAL OF PANCREATOLOGY : OFFICIAL JOURNAL OF THE INTERNATIONAL ASSOCIATION OF PANCREATOLOGY 1995; 17:23-8. [PMID: 8568331 DOI: 10.1007/bf02788355] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The aim of this study was to assess the incidence of fusion and duplication variants of the pancreatic duct system and their clinical significance. A total of 650 endoscopic retrograde cholangiopancreatography were reviewed; 485 cases with satisfactory imaging of the pancreatic ducts were included in the study. Anatomic variants were observed in 48 patients (9.9%), fusion variants were 54.1% of the cases (22 pancreas divisum and 4 functional divisum), and duplication variants were 45.8% (13 bifurcations of the main pancreatic duct, 4 loop, 2N-shape, 3 ring). Clinical indications to endoscopic cholangiopancreatography were idiopathic acute pancreatitis (33.3%), suspected chronic pancreatitis (18.7%), unexplained abdominal pain (14.5%), suspected pancreatic mass (10.4%), chronic hyperamylasemia (6.2%), and acute biliary pancreatitis (16.6%). Except for acute biliary pancreatitis (significantly more frequent in duplication variants), no statistical difference was observed between the groups with anatomical variants concerning clinical features.
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Affiliation(s)
- G Uomo
- Pancreatic Disease Centre-Internal Medicine Department, Cardarelli Hospital, Napoli, Italy
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32
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Robert JY, Bretagne JF, Raoul JL, Siproudhis L, Heresbach D, Gosselin M. Recurrent cholangitis caused by the migration of pancreatic calculi associated with pancreas divisum. Gastrointest Endosc 1993; 39:452-4. [PMID: 8514086 DOI: 10.1016/s0016-5107(93)70130-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- J Y Robert
- Department of Hepato-gastroenterology and Digestive Endoscopy, University Hospital Pontchaillou, Rennes, France
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33
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Affiliation(s)
- P Grech
- Department of Radiology, Duke University Medical Center, Durham, North Carolina
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