Clinical relevance of an unfused pancreatic duct system.

Abstract

SUMMARY In man, the main pancreatic duct is normally derived from ventral and dorsal embryological buds of the pancreas. In a minority of people, failure of fusion of the two buds results in separate drainage of the dorsal and ventral pancreas, so that the accessory duct provides the main drainage for the gland. Patients with this anomaly demonstrated at endoscopic retrograde pancreatography (ERP) have been investigated to assess whether non-fusion of the main pancreatic duct predisposes to the development of pancreatitis. A failure of fusion of the pancreatic ducts was seen in 21 out of 449 (4-7 %) successful pancreatograms; four of these 21 patients had definite clinical evidence of pancreatitis and two patients had possible pancreatic disease, but in the remainder the anomaly was not considered to be clinically relevant. An abnormal pancreatogram suggesting pancreatitis was present in 116 out of the 428 patients (27.1 %) with a normally fused duct system. The anomaly was found as frequently in the whole series as it was seen in patients with pancreatitis. These findings suggest that embryological failure of pancreatic duct fusion does not predispose to the development of pancreatitis. However, the presence of this anomaly may lead to misinterpretation of ultrasonographic and CT scan findings.The pancreas is formed embryologically from distinct ventral and dorsal buds which arise from the duodenal diverticulum after rotation of the ventral bud and have fused by the seventh week of life (Meckel, 1812). Wirsung (1642) first demonstrated the main pancreatic duct in man and Santorini (1775) accurately described the duct system and demonstrated the accessory pancreatic duct.Normally, the main pancreatic duct is derived from both embryological parts of the pancreas; the dorsal pancreas provides the main duct in the tail and body of the gland with the ventral anlage providing the main duct in the head of the gland. The accessory duct (of Santorini) is the remaining portion of the duct in the dorsal pancreas which may drain through an accessory papilla more proximally in the duodenal loop.It is thus not surprising that anomalies of the pancreatic duct system occur and their frequency has been documented in large systematic necropsy studies by Baldwin

Endoscopic Retrograde Cholangiopancreatography (ERCP) in the Diagnosis of Biliary and Pancreatic Duct Disease: a Prospective Study on 668 Jordanian Patients

“…In several reported series of cases examined by ERCP, pancreatic divisum has been recognized in 0.3% to 5.8% of the cases. 9,10 In this study, pancreatic divisum was found in 34 patients (5.1%). Duodenal diverticula are acquired lesions.…”

Impacted Papilla Minor Stone in Pancreas divisum Causing Severe Acute Pancreatitis

“…It was first described by Hyrtl [1]in 1865 and is found in about 5–7% of the general population. The exact frequency in autopsy studies ranges from 4 to 11% [2, 3, 4]and in endoscopic pancreaticographic studies from 1.6 to 5.8% [5, 6, 7, 8, 9]. …”

Endoscopic Therapy of Chronic and Recurrent Pancreatitis

“…Pancreas divisum is found in up to 10% of autopsy studies [35][36][37][38][39][40] and in 2-7% of the elective retrograde cholangiopancreatography series [41][42][43][44]. It is believed that when present in association with stenosis of the minor papilla, it causes resistance to pancreatic flow and may be responsible for patients presenting with acute recurrent pancreatitis and less certain for abdominal pain [41][42][43][44].…”

“…It is believed that when present in association with stenosis of the minor papilla, it causes resistance to pancreatic flow and may be responsible for patients presenting with acute recurrent pancreatitis and less certain for abdominal pain [41][42][43][44].…”

“…Current endoscopic treatment is aimed at improving drainage via the minor papilla either by placement of an endoprosthesis or sphincterotomy [41][42][43][44][45] (fig. 5).…”