Pancreas divisum is a congenital anomaly in the

anatomy Anatomy () is the branch of morphology concerned with the study of the internal structure of organisms and their parts. Anatomy is a branch of natural science that deals with the structural organization of living things. It is an old scien ...

of the ducts of the

pancreas The pancreas (plural pancreases, or pancreata) is an Organ (anatomy), organ of the Digestion, digestive system and endocrine system of vertebrates. In humans, it is located in the abdominal cavity, abdomen behind the stomach and functions as a ...

in which a single

pancreatic duct The pancreatic duct or duct of Wirsung (also, the major pancreatic duct due to the existence of an accessory pancreatic duct) is a duct joining the pancreas to the common bile duct. This supplies it with pancreatic juice from the exocrine pancre ...

is not formed, but rather remains as two distinct dorsal and ventral ducts. Most individuals with pancreas divisum remain without symptoms or complications. A minority of people with pancreatic divisum may develop episodes of abdominal pain, nausea or vomiting due to acute or

chronic pancreatitis Chronic pancreatitis is a long-standing inflammation of the pancreas that alters the organ's normal structure and functions. It can present as episodes of acute inflammation in a previously injured pancreas, or as chronic damage with persistent p ...

. The presence of pancreas divisum is usually identified with cross sectional diagnostic imaging, such as

endoscopic retrograde cholangiopancreatography Endoscopic retrograde cholangiopancreatography (ERCP) is a technique that combines the use of endoscopy An endoscopy is a procedure used in medicine to look inside the body. The endoscopy procedure uses an endoscope to examine the interior ...

(ERCP) or

magnetic resonance cholangiopancreatography Magnetic resonance cholangiopancreatography (MRCP) is a medical imaging technique. It uses magnetic resonance imaging to visualize the biliary and pancreatic ducts non-invasively. This procedure can be used to determine whether gallstones are lod ...

(MRCP). In some cases, it may be detected intraoperatively. If no symptoms or complications are present, then treatment is not necessary. However, if there is recurrent pancreatitis, then a sphincterotomy of the minor papilla may be indicated.

Causes

The human embryo begins life with two ducts in the

, the ventral duct and the dorsal duct. Normally, the two ducts will fuse together to form one main pancreatic duct; this occurs in more than 90% of embryos. In approximately 10% of embryos the ventral and dorsal ducts fail to fuse together, resulting in pancreas divisum. In utero, the majority of the pancreas is drained by the dorsal duct which opens up into the

minor duodenal papilla The minor duodenal papilla is the opening of the accessory pancreatic duct into the descending second section of the duodenum. Structure The minor duodenal papilla is contained within the second part of the duodenum. It is situated 2 cm prox ...

. The ventral duct drains the minority of the pancreas and opens into the

major duodenal papilla The major duodenal papilla (papilla of Vater) is a rounded projection in the duodenum into which the common bile duct and pancreatic duct drain. The major duodenal papilla is, in most people, the primary mechanism for the secretion of bile and ot ...

. In adults however, this situation is reversed whereby 70% of the pancreas is drained by the ventral duct. Therefore in pancreas divisum, where fusion of the ducts does not occur, the major drainage of the pancreas is done by the dorsal duct which opens up into the minor papilla.

Diagnosis

The most common and accurate way of diagnosing an individual with this anomaly is by ERCP and MRCP. This test can demonstrate the presence of two separately draining ducts within the pancreas Pancreas divisum has been suggested as a potential contributor of chronic pancreatitis in certain cases. The separate ducts could lead to poor drainage of pancreatic secretions and increased pressure in the dorsal duct, increasing the risk of inflammation and the development of complications. As a result, pancreas divisum is found more commonly in patients with pancreatitis.

Treatment

Pancreas divisum in individuals with no symptoms does not require treatment. For cases with mild and infrequent attacks, management may involve a low-fat diet, medications to reduce pain and gastrointestinal reactions, and pancreatic enzyme supplementation. A surgeon may attempt a

sphincterotomy Anal sphincterotomy is a surgical procedure that involves treating mucosal fissures from the anal canal/sphincter. The word is formed from sphincter + otomy (to cut, to separate). Procedure # The surgery can be performed under any kind of anesthe ...

by cutting the minor papilla to enlarge the opening and allow

pancreatic enzymes Digestive enzymes take part in the chemical process of digestion, which follows the mechanical process of digestion. Food consists of macromolecules of proteins, carbohydrates, and fats that need to be broken down chemically by digestive enzymes ...

to flow normally. During surgery, a stent may be inserted into the duct to ensure that the duct will not close causing a blockage. This surgery can cause pancreatitis in patients, or in rare cases, kidney failure and death. ERCP are sometimes used for symptomatic pancreas divisum, which offers the benefit of a less invasive approach compared with surgery. No large-scale clinical studies comparing surgical and endoscopic approaches are available.

Occurrence

Studies involving autopsy and imaging series indicate that between 6% and 10% of the population have pancreas divisum, but it is asymptomatic in the majority (>95%) of cases. In those who develop symptoms, the symptoms seen in pancreas divisum and pancreatitis with typical anatomy are the same:

abdominal pain Abdominal pain, also known as a stomach ache, is a symptom associated with both non-serious and serious medical issues. Since the abdomen contains most of the body's vital organs, it can be an indicator of a wide variety of diseases. Given th ...

is common, typically of sudden onset and located in the right upper quadrant of the abdomen and often accompanied by

nausea Nausea is a diffuse sensation of unease and discomfort, sometimes perceived as an urge to vomit. It can be a debilitating symptom if prolonged and has been described as placing discomfort on the chest, abdomen, or back of the throat. Over 30 d ...

and

vomiting Vomiting (also known as emesis, puking and throwing up) is the forceful expulsion of the contents of one's stomach through the mouth and sometimes the nose. Vomiting can be the result of ailments like food poisoning, gastroenteritis, pre ...

. Pancreatic pain is characteristically described as a constant, severe, dull, epigastric pain that often radiates to the back and typically worsens after high-fat meals. However, many different pain patterns have been described, ranging from no pain to recurrent episodes of pain and pain free intervals, to constant pain with clusters of severe exacerbations.

References

External links

* {{Congenital malformations and deformations of digestive system Congenital disorders of digestive system Pancreas disorders Anatomical variations