From the Guidelines
Management of a patient with suspected pancreas divisum undergoing abdominal MRI should include MRCP (Magnetic Resonance Cholangiopancreatography) protocol with secretin enhancement. This approach is based on the most recent and highest quality study available, which emphasizes the importance of specialized imaging techniques for visualizing the separate drainage systems in pancreas divisum 1.
Key Considerations for MRI Protocol
- The patient should fast for 4-6 hours prior to the examination to reduce gastrointestinal motility and empty the stomach.
- Administration of intravenous secretin (0.2-0.3 mcg/kg) during the procedure stimulates pancreatic secretions, improving visualization of the pancreatic ductal system.
- Anti-peristaltic agents such as glucagon (0.5-1 mg IV) or hyoscine butylbromide (20 mg IV) may be given immediately before imaging to reduce motion artifacts.
- Gadolinium-based contrast (0.1 mmol/kg) should be included for assessment of parenchymal abnormalities.
Importance of Radiologist Notification
The radiologist should be specifically informed about the suspicion of pancreas divisum to ensure appropriate imaging sequences and focused interpretation. This is crucial because pancreas divisum requires specialized imaging techniques to identify potential complications such as chronic pancreatitis or ductal obstruction that may be contributing to the patient's symptoms 1.
Clinical Context and Decision Making
In the context of suspected pancreas divisum, the decision to proceed with endoscopic therapy, such as minor papilla endotherapy, should be carefully considered, particularly for patients with objective signs of outflow obstruction 1. However, the primary approach for diagnosis and initial assessment remains the use of MRI with MRCP and secretin enhancement, as it provides valuable information on the pancreatic ductal system without the risks associated with invasive procedures 1.
From the Research
Management Approach for Pancreas Divisum
The management approach for a patient with suspected pancreas divisum undergoing an MRI of the abdomen involves several steps:
- Diagnosis: Pancreas divisum is a congenital abnormality of the pancreas that results from the lack of fusion between the dorsal and ventral pancreatic ducts during fetal development 2.
- Imaging: Magnetic Resonance Cholangiopancreatography (MRCP) is a useful imaging modality for diagnosing pancreas divisum, as it can demonstrate non-communicating dorsal and ventral ducts, independent drainage sites, a dominant dorsal pancreatic duct, and a small cystic dilatation of the dorsal duct at the minor papilla (santorinocoele) 2.
- Symptoms: Patients with pancreas divisum may present with unexplained episodes of abdominal pain, mild pancreatitis, or incidentally 2.
- Treatment: The treatment approach for pancreas divisum depends on the presence and severity of symptoms. For patients with symptomatic pancreas divisum, endoscopic retrograde cholangiopancreatography (ERCP) with minor papilla cannulation and stent placement may be beneficial 3, 4, 5.
- Surgical Treatment: Surgical treatment, such as pancreatic head resection with segmental duodenectomy (the Nakao procedure), may be necessary in cases of endoscopic drainage failure or complications such as chronic pancreatitis and local complications 6.
Diagnostic Modalities
The diagnostic modalities for pancreas divisum include:
- MRCP: A non-invasive imaging modality that can demonstrate the pancreatic ductal anatomy 2.
- ERCP: An invasive imaging modality that can demonstrate the pancreatic ductal anatomy and allow for therapeutic interventions such as stent placement 3, 4, 5.
- Morphine prostigmine stimulation: A screening tool that can help identify patients with pancreas divisum who may benefit from therapeutic interventions 3.
Treatment Outcomes
The treatment outcomes for pancreas divisum vary depending on the treatment approach and the presence and severity of symptoms. A study of 20 patients with pancreas divisum who underwent dual sphincteroplasty reported a 70% response rate, with 2 patients experiencing recurrent pancreatitis and 4 patients experiencing other problems causing continued post-operative pain 3. Another study of 45 patients with pancreas divisum who underwent ERCP reported an overall response rate of 75.8% 5.