Pancreas Divisum

Pancreas divisum is the commonest congenital pancreatic anomaly, resulting from failure of fusion of the dorsal and ventral pancreatic duct systems.

• Prevalence 5 to 10% of the population (autopsy), and 3 to 5% on ERCP.
• Most of the pancreas drains through the minor papilla via the duct of Santorini, which may be relatively obstructive.
• Most people are asymptomatic. Associated with CFTR and SPINK1 mutations in patients with recurrent pancreatitis.
• Variants: complete divisum, incomplete (small ventral communication), reverse divisum.
• Role in pancreatitis remains debated, probably only in those with relative minor papilla stenosis.

• Asymptomatic in over 95%.
• Recurrent acute pancreatitis, abdominal pain (pancreatic type), chronic pancreatitis.
• Idiopathic pancreatitis, particularly in younger patients.
• Exclude other causes: alcohol, gallstones, hypertriglyceridaemia, genetic mutations.

• MRCP: dorsal duct crossing anterior to the common bile duct and draining to the minor papilla, a short ventral duct (secretin enhanced MRCP improves detection and shows dorsal duct dilatation).
• Endoscopic ultrasound: dominant dorsal duct with ventral duct not communicating (stack sign).
• ERCP: cannulation of the major papilla shows a short ventral duct; minor papilla cannulation confirms dorsal drainage.
• Evaluate other causes of pancreatitis: genetic testing (PRSS1, SPINK1, CFTR, CTRC), IgG4, triglycerides, calcium, autoimmune markers.
• Exclude obstructing lesions of the minor papilla.

• Asymptomatic: no treatment.
• Recurrent acute pancreatitis (idiopathic) with divisum: endoscopic minor papilla sphincterotomy (needle knife or pull type) with or without dorsal duct stenting (3 to 5 Fr, short, for 1 to 3 months); reduces pancreatitis recurrence in 70 to 80%. Post ERCP pancreatitis prophylaxis with rectal indomethacin 100 mg and pancreatic stent.
• Chronic pain without pancreatitis: poor response to sphincterotomy; treat as chronic pancreatitis, analgesic ladder, pancreatic enzymes.
• Surgical minor papilla sphincteroplasty with or without accessory duct drainage for failures; pancreaticojejunostomy for chronic pancreatitis with dilated duct.
• Genetic counselling if CFTR or SPINK1 mutations.
• Avoid alcohol and smoking. Follow up for pancreatic exocrine insufficiency and diabetes.