PANEL A PANEL B

CT of “real” pancreas divisum

Nine-years old girl has been suffering of numerous attacks of pancreatitis. Her clinical findings was normal. Blood biochemistry was normal except increased urinary amylase and serum lipase levels. Abdominal ultrasound scan was normal.

Endoscopic retrograde cholangiopancreatography (ERCP) demonstrated pancreas divisum. After the major papilla cannulation short ventral pancreatic duct (duct of Wirsung) was opacified. Than the minor papilla cannulation was succesfully performed revealing a dorsal duct (duct of Santorini) running the entire lenght of the pancreas without communicating with the duct of Wirsung. Santorini duct drainage of the dorsal pancreas through the minor papilla was very slow.( PANEL A ).

Abdominal CT showed variant of pancreas divisum in which not only ducts of the dorsal and ventral pancreatic primordium failed to fuse. The whole ventral pancreas and dorsal pancreatic lobes remains separated thus presented itself as separated glands, “real” pancreas divisum. ( PANEL B ).

Surgical transduodenal ( minor papilla ) sphincteroplasty was successfully performed by one of us (BR) leading to girl^,s full clinical and laboratory recovery.

Strictly speaking pancreas divisum indicates a failure of the ventral and dorsal duct to communicate when the ventral and dorsal anlage (lobes) rotate and fuse. Frequently, the ventral duct is absent, requiring that all of the pancreatic secretions pass through the accessory papilla. There is belief that relative accessory papilla stenosis superimposed on the anatomical circumstances lead to increased pressure in the dorsal duct and obstructive pancreatitis (1).

The unusal feature of this paediatric patient is that the pancreas divisum involved not just the unjoined ducts but also the external morphology of the dorsal and ventral pancreatic segments. It has to be stressed that pancreas divisum is usually not discernible by naked surgeon^,s eye or abdominal imaging. This case demonstrates that pancreas divisum does not means that only the internal ductal system is divided (2). In some cases of pancreas divisum gland is “really” grossly devided (2). Further studies are necessary to determine whether this variant of pancreas divisum predisposes afflicted patients to more serious pancreatic illness necessitating surgery. This case probaly indicate that beside ERCP, abdominal CT has to included in the diagnostic protocol of ERCP diagnosed pancreas divisum.

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Pancreas divisum by CT Gastroenterološka sekcija SLD-

01741,2002.

¹Dr Vojislav Perišić

²Dr Sandra Nedović,

¹Dr Mira Petrović,

¹Department of Hepatology and Gastrointestinal Endoscopy, and ²Radiology,

University Children^,s Hospital, Belgrade.

Dr Božina Radević

Department of Surgery, Institute for Cardiovascular Disease “Dedinje”, Belgrade.

Dr Radmilo Krstić

Dr Viktorija Korneti

Institute of Digestive Diseases,

Clinical Center of Serbia, Belgrade.

REFERENCES:

1.Warshaw AL, Simeone JF, Schapiro RH, Falvin-Warshaw B. Evaluation and treatment of the dominant dorsal duct syndrome. Am J Surg 1990; 159:59-68.

2.Warchaw AL. Pancreas divisum-really. Surgery 2000; 128:1-3.