From the Guidelines
Patients with pancreatic divisum and no discrete focal lesions should not undergo endoscopic retrograde cholangiopancreatography (ERCP) for abdominal pain alone, but may be considered for minor papilla endotherapy if they have objective signs of outflow obstruction, such as a dilated dorsal pancreatic duct and/or santorinicele, as this may help reduce the frequency of acute pancreatitis episodes. Pancreatic divisum is a congenital anatomical variant where the pancreatic ducts fail to fuse during fetal development, resulting in separate drainage systems for the pancreas [ 1 ]. When no focal lesions are present, this condition is often asymptomatic and requires no specific treatment. However, if symptoms like recurrent abdominal pain or pancreatitis are present, medical management is recommended, including lifestyle modifications such as avoiding alcohol, maintaining a low-fat diet, and smoking cessation [ 1 ].
Key Considerations
- The decision to proceed with endoscopic therapy in patients with recurrent acute pancreatitis (RAP) and pancreatic divisum should be carefully considered in the context of potential adverse events, including a 10%–15% risk of post-ERCP pancreatitis and the consequences of post-papillotomy stenosis [ 1 ].
- Patients with overt radiologic findings of ductal outflow obstruction may be more likely to benefit from endoscopic therapy, although evidence-based predictors of response are yet to be defined [ 1 ].
- Regular follow-up with a gastroenterologist is important to monitor for any changes or complications [ 1 ].
Management Options
- Medical management, including lifestyle modifications and pain management with medications like pancreatic enzyme supplements, may help some patients [ 1 ].
- Endoscopic retrograde cholangiopancreatography (ERCP) with minor papilla sphincterotomy or stent placement may be considered to improve drainage from the dorsal pancreatic duct in symptomatic patients [ 1 ].
From the Research
Pancreatic Divisum with No Discrete Focal Lesions
- Pancreas divisum is a congenital embryological disease caused by a lack of fusion between the ventral and dorsal pancreatic ducts in the early stages of embryogenesis 2.
- It is a common pancreatic malformation, but only a few patients develop symptomatic disease 2, 3.
- The main clinical syndromes at presentation include recurrent acute pancreatitis, chronic pancreatitis, or chronic abdominal pain, which occur in only 5% of patients with pancreas divisum 2.
Diagnosis and Treatment
- Diagnosis of pancreas divisum can be made using various diagnostic modalities, and treatment strategies include surgical and endoscopic techniques 2.
- Minor papilla sphincterotomy (miES) is offered in clinical practice to patients with idiopathic acute recurrent pancreatitis (iRAP) and pancreas divisum, but available data originate mainly from observational studies with many limitations 4.
- Endoscopic therapy for pain relief has limited to no benefit in patients with chronic abdominal pain or chronic pancreatitis who have pancreas divisum and is not recommended 4.
Management of Pancreas Divisum
- Surgical treatment is needed in case of endoscopic drainage failure and in cases complicated with chronic pancreatitis and local complications 2.
- Many techniques, of greater or lesser complexity, have been proposed for the surgical treatment of pancreas divisum 2.
- Current research fails to define a clear association between pancreas divisum and pancreatic disease, and a comprehensive discussion with the individual patient is necessary to define expectations before embarking on any medical and/or interventional therapy 3.