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Paper 2
Published in Amanda Rabone, Benedict Thomson, Nicky Dineen, Vincent Helyar, Aidan Shaw, The Final FRCR, 2020
Amanda Rabone, Benedict Thomson, Nicky Dineen, Vincent Helyar, Aidan Shaw
Pancreas divisum is the commonest congenital pancreatic abnormality caused by failure of ductal fusion leading to two ducts draining into the duodenum. MRCP and MRI pancreas is the most helpful test to diagnose the condition. It does not cause duodenal luminal narrowing.
Chronic pancreatitis
Published in David Westaby, Martin Lombard, Therapeutic Gastrointestinal Endoscopy A problem-oriented approach, 2019
Obstruction of the pancreatic duct due to trauma, stenosis, adenoma, malignant stricture or papillary dyskinesia can lead to chronic pancreatitis. Pancreas divisum remains controversial as a cause – it occurs in 4–7% of the general population but only a tiny fraction of these present with pancreatitis. Nonetheless, it is found in between 7% and 50% of patients presenting with pancreatitis, and many clinicians believe it is implicated, though the mechanisms remain unclear and attempts at improving dorsal duct drainage have not been conclusively beneficial.
The pancreas
Published in Professor Sir Norman Williams, Professor P. Ronan O’Connell, Professor Andrew W. McCaskie, Bailey & Love's Short Practice of Surgery, 2018
Professor Sir Norman Williams, Professor P. Ronan O’Connell, Professor Andrew W. McCaskie
Pancreas divisum occurs when the embryological ventral and dorsal parts of the pancreas fail to fuse (Figure68.3). The dorsal pancreatic duct becomes the main pancreatic duct and drains most of the pancreas through the minor or accessory papilla. The incidence of pancreas divisum ranges from 5% in autopsy series to 10% in some ERCP and MRCP series. Pancreas divisum found incidentally in an asymptomatic person does not warrant any intervention. But the incidence of pancreas divisum ranges from 25-50% in patients with recurrent acute pancreatitis, chronic pancreatitis and pancreatic pain. The minor papilla is substantially smaller than the major papilla (and many of these patients probably have papillary stenosis). A large volume of secretions flowing through a narrow papilla probably leads to incomplete drainage, which may then cause obstructive pain or pancreatitis. Certainly in patients with idiopathic recurrent pancreatitis, pancreas divisum should be excluded. The diagnosis can be arrived at by MRCP, EUS or ERCP, augmented by injection of secretin if necessary. There may be changes indicative of obstruction or chronic inflammation in the dorsal duct system. Endoscopic sphincterotomy and stenting of the minor papilla may relieve the symptoms. Surgical intervention can take the form of sphincteroplasty, pancre- atojejunostomy or even resection of the pancreatic head.
Impact of genetic testing and smoking on the distribution of risk factors in patients with recurrent acute and chronic pancreatitis
Published in Scandinavian Journal of Gastroenterology, 2022
Merve Gurakar, Niloofar Y. Jalaly, Mahya Faghih, Tina Boortalary, Javad R. Azadi, Mouen A. Khashab, Christopher Fan, Anthony N. Kalloo, Atif Zaheer, Vikesh K. Singh, Elham Afghani
Our study showed that 20.8% of patients with idiopathic pancreatitis have pancreas divisum, consistent with prior studies [46–48]. More importantly, we showed that 72% of patients with pancreas divisum have an environmental and/or genetic risk factor for pancreatitis. Among these patients, the most common risk factors were pathogenic variant(s) and smoking. Recent studies have shown a strong association between pancreas divisum and pathogenic variants, particularly CFTR, in the development of pancreatitis [29,30]. CFTR expression is the highest in the pancreas [49,50], which may explain why disease modification with CFTR modulators has the greatest impact there. The expanding number of ‘small effect’ variants will likely explain pancreatitis in a larger percentage of these patients over time. For example, a recent case series showed co-occurrence of risk variants in susceptibility gene loci (CFTR, CEL, and PRSS1) with variants in GGT1 and UBR1 protective/adaptive gene loci as the mechanisms of pancreatitis risk variants in patients with AP, RAP and CP [51]. Elucidating these risk factors may help avoid unnecessary ERCP with minor papillotomy which is currently being studied in sham-controlled trial [52]. In a study of Chinese patients with idiopathic CP, those carrying a SPINK1 c.194 + 2 T > C mutations were less likely to achieve pain relief through endoscopic treatments [42].
Pancreas divisum and recurrent pancreatitis: long-term results of minor papilla sphincterotomy
Published in Scandinavian Journal of Gastroenterology, 2019
Andrea Tringali, Theodor Voiosu, Tommaso Schepis, Rosario Landi, Vincenzo Perri, Vincenzo Bove, Andrei Mihai Voiosu, Guido Costamagna
Pancreas divisum (PD) is the most common congenital variation of the pancreas, resulting from a lack of fusion between the ventral and dorsal buds of the pancreas. As a result, the dorsal pancreatic duct drains the majority of the pancreatic parenchyma via the minor papilla, while the ventral pancreas drains into the major papilla through a short ventral duct. This condition can be found in near 5–10% of the population [1,2] and, while in most cases it remains asymptomatic, it can sometimes become relevant because of a relative obstruction of pancreatic juice at the level of the minor papilla. A diagnosis of pancreas divisum is usually associated with one of three types of presentation: (1) acute recurrent pancreatitis (ARP), (2) chronic pancreatitis (CP) and (3) pancreatic-type pain without pancreatitis (pain with ‘pancreatic’ clinical pattern in the absence of increasing serum amylase or lipase 3 times upper the normal limit and or imaging criteria) [3].
Incidence and risk factors for post-ERCP pancreatitis in pancreas divisum patients without chronic pancreatitis
Published in Scandinavian Journal of Gastroenterology, 2020
Qian-Qian Meng, Sheng-Bing Zhao, Zhi-Jie Wang, Zhen Shen, Tian Xia, Shu-Ling Wang, Lun Gu, Peng Pan, Zhao-Shen Li, Jun Yao, Yi-Hai Shi, Yu Bai
Pancreas divisum (PD) is a kind of congenital variant of the pancreas, in which one single pancreatic duct is not formed by the ventral and dorsal ducts during organogenesis [1,2]. The incidence of PD is about 10% in embryos and most majority of PD are asymptomatic, which may be only detected by autopsy [3,4]. The common symptoms for a small number of symptomatic PDs contain abdominal pain, nausea, acute and chronic pancreatitis (CP) [5]. ERCP (Endoscopic Retrograde Cholangiopancreatography) remains the gold standard for the diagnosis of PD. In our previous study, the endoscopic detection rate of PD has been found to be 2.9% [6]. Patients with symptomatic PD are most likely to benefit from endoscopic intervention on the dorsal duct in 58% to 90% of patients [7–9].