Table of Contents
Introduction
Pancreas divisum is a common anatomical anomaly that occurs in ~4-14% of the general population [1]. It arises during development when two precursors of the pancreas do not fuse together properly. The developing pancreas contains two pancreatic ducts or tubes called the dorsal duct and the ventral duct. These ducts fuse together to form a single main pancreatic duct. The pancreatic duct joins the pancreas to the digestive system to supply pancreatic juice for digestion. For some individuals, a small connection remains between these two ducts of the pancreas and, in others, there is a complete disconnect between them. For an illustration of pancreas divisum, see the two illustrations in the bottom right of Figure 1 below.
Figure 1: Anatomy of Pancreas Divisum [2]
Diagnosis of Pancreas Divisum
The vast majority of individuals with pancreas divisum do not experience symptoms and the condition is typically only identified if an autopsy is performed. If specific abdominal symptoms are present, a doctor may seek additional medical imaging, like an MRCP or an ERCP. During these imaging tests, pancreas divisum may be detected [3].
Pancreas Divisum & Pancreatitis
Pancreas divisum has been associated with pancreatic disease [4], although the specific mechanisms that cause disease are not fully known. Complete pancreas divisum and incomplete pancreas divisum present with pancreatitis at different rates, which implies there are differences between each that influence the onset of the disease.
If pancreas divisum directly caused pancreatitis in all individuals, researchers would expect many more patients with pancreas divisum to present with pancreatitis. This is not the case. However, pancreas divisum has been found to be significantly overrepresented in individuals with pancreatitis and genetic risk variants in the PRSS1, SPINK1 and CFTR genes [5]. Studies suggest that pancreas divisum may modify risk for pancreatitis in some individuals with a genetic predisposition. A more complex understanding of pancreatic disease must be considered to fully understand what genetic, environmental, or lifestyle factors could trigger a bout of pancreatitis in those with pancreas divisum.
Treatment Options
The treatment of pancreatitis in the presence of pancreas divisum begins conservatively with intravenous (IV) fluids to keep the patient hydrated and analgesics, as appropriate [6]. If these measures are not sufficient to manage pain and chronic pancreatitis develops, more invasive options can be considered, however, there are no guarantees of symptom remission.
A doctor can attempt to dilate, or widen, the pancreatic duct and place a stent [7] to support the duct’s structure. Additionally, a sphincterotomy can be considered [8]. During a pancreatic sphincterotomy, the tissue of the pancreas is cut by a surgeon to alleviate symptoms. Resection, or removal, of pancreatic tissue can also be considered in more serious cases of chronic pancreatitis, however, this more aggressive treatment strategy is rare.
Conclusion
Similar to how humans display anatomical variety outwardly, variation can also occur within the body. Pancreas divisum is an example of this, and it is a common anatomical variation. For most, pancreas divisum causes no symptoms and they live life without knowledge of this condition. For others, pancreas divisum may be at the root of pancreatitis and pancreatic disease. Because the condition manifests itself physically, treatment options for more serious cases include surgery to remedy the abnormal structures in the pancreas.
Additional research is required to better understand why pancreas divisum forms during development and what genetic, environmental, or lifestyle factors contribute to the onset of pancreatitis in individuals with pancreas divisum. If you have been diagnosed with pancreas divisum, speak to your healthcare provider about the details of your situation because each case is unique.
References
- Kuzel AR, Lodhi MU, Rahim M. Pancreatic Divisum: An Unusual Cause of Chronic Pancreatitis in a Young Patient. Cureus. 2017;9(11):e1856. Published 2017 Nov 17. doi:10.7759/cureus.1856
- Luther J., Casey B.W. (2016) Pancreas Divisum and Minor Papilla Interventions. In: Adler D. (eds) Advanced Pancreaticobiliary Endoscopy. Springer, Cham. https://doi.org/10.1007/978-3-319-26854-5_9
- Anomalies, Anatomic Variants, and Sources of Diagnostic Pitfalls in Pancreatic Imaging, Peyman Borghei, Farnoosh Sokhandon, Ali Shirkhoda, and Desiree E. Morgan, Radiology 2013 266:1, 28-36
- Takuma, K., Kamisawa, T., Tabata, T., Egawa, N. and Igarashi, Y., 2010. Pancreatic Diseases Associated with Pancreas Divisum. Digestive Surgery, 27(2), pp.144-148.
- Bertin C, Pelletier AL, Vullierme MP, Bienvenu T, Rebours V, Hentic O, Maire F, Hammel P, Vilgrain V, Ruszniewski P, Lévy P. Pancreas divisum is not a cause of pancreatitis by itself but acts as a partner of genetic mutations. Am J Gastroenterol. 2012 Feb;107(2):311-7. doi: 10.1038/ajg.2011.424. Epub 2011 Dec 13. PMID: 22158025.
- Ng WK, Tarabain O. Pancreas divisum: a cause of idiopathic acute pancreatitis. CMAJ. 2009;180(9):949-951. doi:10.1503/cmaj.080446
- Cohen SA, Rutkovsky FD, Siegel JH, Kasmin FE. Endoscopic stenting and sphincterotomy of the minor papilla in symptomatic pancreas divisum: results and complications. Diagn Ther Endosc. 1995;1(3):131-139. doi:10.1155/DTE.1.131
- Buscaglia JM, Kalloo AN. Pancreatic sphincterotomy: technique, indications, and complications. World J Gastroenterol. 2007;13(30):4064-4071. doi:10.3748/wjg.v13.i30.4064
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