Pancreatic divisum

Pancreatic divisum is a common congenital anomaly of the pancreas where the ductal system of the pancreas is divided. It occurs due to the failure of the dorsal and ventral pancreatic ducts to fuse during embryonic development. This condition is present in approximately 5-10% of the population, but most individuals remain asymptomatic and are unaware of the condition. However, in a subset of patients, pancreatic divisum can lead to recurrent episodes of pancreatitis.

Etiology

Pancreatic divisum results from an anomaly in the development of the pancreatic ductal system. During the sixth week of embryonic development, the pancreas forms from two separate buds on the duodenum, the dorsal and ventral ducts. Normally, these ducts fuse to form a single ductal system. In pancreatic divisum, this fusion fails to occur, leaving the dorsal and ventral ducts separate.

Pathophysiology

In individuals with pancreatic divisum, the majority of the pancreas (the part derived from the dorsal bud) drains through the minor papilla via the dorsal duct, while only a small portion (derived from the ventral bud) drains through the major papilla via the ventral duct. This altered drainage pattern can lead to inadequate drainage of pancreatic secretions, which may contribute to the development of pancreatitis in some patients.

Clinical Presentation

Many people with pancreatic divisum are asymptomatic. When symptoms do occur, they often present as recurrent episodes of pancreatitis. Symptoms of pancreatitis include severe abdominal pain, nausea, vomiting, and elevated pancreatic enzymes in the blood. Chronic pancreatitis can also lead to complications such as diabetes mellitus and exocrine pancreatic insufficiency.

Diagnosis

The diagnosis of pancreatic divisum is often made incidentally during imaging studies performed for other reasons. Magnetic resonance cholangiopancreatography (MRCP) is the non-invasive imaging modality of choice for visualizing the pancreatic ductal anatomy. Endoscopic retrograde cholangiopancreatography (ERCP) can also be used for diagnosis and therapeutic interventions.

Treatment

Treatment of pancreatic divisum is primarily aimed at managing symptoms, particularly in patients with recurrent pancreatitis. Endoscopic minor papillotomy, where the minor papilla is cut to facilitate drainage of the dorsal duct, can be performed in symptomatic individuals. In some cases, pancreatic enzyme supplements and pain management are necessary to manage symptoms of chronic pancreatitis.

Prognosis

The prognosis for individuals with pancreatic divisum varies. Many individuals remain asymptomatic throughout their lives and require no treatment. In patients who develop pancreatitis, the prognosis depends on the severity of the pancreatitis and the effectiveness of treatment strategies to manage symptoms and prevent complications.