What is the best management approach for a patient with pancreatic divisum and recurrent acute pancreatitis?

Management of Pancreatic Divisum with Recurrent Acute Pancreatitis

For patients with pancreatic divisum and recurrent acute pancreatitis, endoscopic minor papilla sphincterotomy is the preferred initial intervention, as it provides effective long-term prevention of recurrent pancreatitis episodes with fewer complications than stenting. 1

Diagnostic Approach

• Pancreatic divisum must be systematically suspected in cases of multiple episodes of acute idiopathic pancreatitis when exhaustive etiological investigations are negative 2
• Diagnosis requires imaging with magnetic resonance cholangiopancreatography (MRCP) or endoscopic retrograde cholangiopancreatography (ERCP) 2
• In patients with recurrent episodes of unexplained pancreatitis, evaluation with endoscopic ultrasonography (EUS) and/or ERCP should be considered, with EUS preferred as the initial test 3

Treatment Options

Endoscopic Management

• Minor papilla sphincterotomy has shown excellent long-term results with:

  • Prevention of recurrent acute pancreatitis in 72.9% of patients 1
  • Improvement in quality of life in 85.4% of patients at long-term follow-up (mean 9.7 years) 1
  • Lower complication rates compared to pancreatic stent insertion (25% vs. 44%) 4

• Dorsal duct stenting:

  • Can be effective but has higher complication rates than sphincterotomy 4
  • May lead to pancreatic duct stenosis and dilatation in some patients 4
  • Should be considered temporary rather than definitive therapy 4

Surgical Management

• Surgical accessory duct sphincteroplasty may be considered for patients who fail endoscopic therapy:
  • Has shown success in 83.8% of patients for long-term prevention of recurrent acute pancreatitis 5
  • May provide superior long-term results compared to endoscopic sphincterotomy in terms of restenosis rates 5
  • However, less effective for chronic pancreatic pain relief 5

Complications and Their Management

• Procedure-related adverse events from endoscopic therapy occur in approximately 13% of cases:

  • Post-sphincterotomy delayed bleeding (6.5%) 1
  • Mild pancreatitis (6.5%) 1
  • Stenosis of the minor papilla (risk factor for recurrent pancreatitis) 1

• Management of complications:

  • Most complications can be managed conservatively 4
  • Restenosis may require repeat endoscopic intervention 1
  • Surgical intervention may be necessary in refractory cases 4

Follow-up Recommendations

• Regular clinical follow-up to monitor for recurrence of pancreatitis symptoms 1
• Imaging follow-up is not routinely required unless there is clinical deterioration 6
• Patients with recurrent symptoms despite endoscopic therapy may require consideration of surgical options 5

Pitfalls and Caveats

• Not all patients with pancreatic divisum develop symptoms; it is present in 5-10% of the general population 2
• Only about 5% of patients with pancreatic divisum develop acute pancreatitis or chronic pancreatitis 2
• Patient selection is crucial - invasive therapy should be reserved for those with documented recurrent acute pancreatitis rather than chronic pain alone 7
• Stenosis of the minor papilla after sphincterotomy is the main risk factor for recurrent pancreatitis after initial therapy 1
• Endoscopists performing minor papilla interventions should have specific training and experience in these technically demanding procedures 3