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Duggal S, Akahara O, Didia C. Chronic Pancreatitis and Pancreas Divisum: A Case Report of Recurrent Management Challenges. Cureus 2025; 17:e82313. [PMID: 40376315 PMCID: PMC12080951 DOI: 10.7759/cureus.82313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2024] [Accepted: 04/15/2025] [Indexed: 05/18/2025] Open
Abstract
Pancreas divisum, resulting from incomplete fusion of the pancreatic ducts during development, disrupts normal drainage and can lead to recurrent acute and chronic pancreatitis. This report presents a case of a 46-year-old male with chronic necrotizing pancreatitis secondary to pancreas divisum. The patient experienced multiple hospital admissions and underwent a cholecystectomy before the underlying etiology, pancreas divisum, was identified after six hospitalizations. This case highlights the diagnostic challenges of recurrent pancreatitis, emphasizing the importance of considering congenital pancreatic anomalies in patients with unexplained or refractory disease. It also underscores the need for a systematic approach to evaluating recurrent pancreatitis to avoid delays in diagnosis and unnecessary interventions. Pancreas divisum is associated with recurrent pancreatitis in a subset of patients. While endoscopic retrograde cholangiopancreatography remains the gold standard for diagnosis and intervention, non-invasive imaging such as magnetic resonance cholangiopancreatography is preferred for initial diagnosis. Endoscopic treatment, including minor papilla papillotomy and stenting, is typically effective for symptomatic cases. However, surgery may be necessary when these methods fail.
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Affiliation(s)
- Shivangini Duggal
- Internal Medicine, Texas Tech University of Health Sciences, El Paso, USA
| | - Ozioma Akahara
- Internal Medicine, Texas Tech University Health Sciences Center El Paso Paul L. Foster School of Medicine, El Paso, USA
| | - Claudia Didia
- Internal Medicine, Texas Tech University Health Sciences Center El Paso Paul L. Foster School of Medicine, El Paso, USA
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Rodriguez J, Coté GA. Clinical and Investigative Approach to Recurrent Acute Pancreatitis. Gastroenterol Clin North Am 2025; 54:113-127. [PMID: 39880522 DOI: 10.1016/j.gtc.2024.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2025]
Abstract
Recurrent acute pancreatitis (RAP) is a complex syndrome that presents variably, with many cases remaining idiopathic after thorough diagnostics. For evaluating structural etiologies, endoscopic ultrasound and MR cholangiopancreatography are preferred over endoscopic retrograde cholangiopancreatography (ERCP) given their more favorable risk profile and sensitivity. The diagnostic work-up remains paramount since treatment should focus on addressing underlying causes such as early cholecystectomy for gallstone pancreatitis. As more etiologic factors are uncovered, such as genetic susceptibility, causality becomes more nuanced. Earlier enthusiasm for endoscopic sphincterotomy as a treatment for idiopathic RAP has been tempered by less favorable studies in recent years.
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Affiliation(s)
- Jennifer Rodriguez
- Division of Gastroenterology and Hepatology, Oregon Health & Science University, Portland, OR, USA
| | - Gregory A Coté
- Division of Gastroenterology and Hepatology, Oregon Health & Science University, Portland, OR, USA.
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Yadlapati S, Gutta A, Fogel EL. Determining the value of endoscopic retrograde cholangiopancreatography in the management of patients with acute pancreatitis and related complications. Expert Rev Gastroenterol Hepatol 2025:1-19. [PMID: 39921919 DOI: 10.1080/17474124.2025.2464057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2024] [Revised: 02/02/2025] [Accepted: 02/04/2025] [Indexed: 02/10/2025]
Abstract
INTRODUCTION Endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a diagnostic to a therapeutic tool in acute pancreatitis management, largely due to the availability of less invasive diagnostic modalities such as endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP). AREAS COVERED This review explores the therapeutic applications of ERCP across various acute pancreatitis etiologies and its role in managing complications such as bile duct obstructions, pancreatic duct disruptions, and infected necrosis. The discussion highlights the procedure's expanding indications and its critical role in addressing complex cases. EXPERT OPINION ERCP remains central to the management of acute pancreatitis complications. As endoscopic techniques and devices continue to advance, its therapeutic scope is likely to grow. Performing ERCP for appropriate indications and optimizing its use is essential for minimizing risks and improving outcomes.
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Affiliation(s)
- Sujani Yadlapati
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indiana University Hospital, Indianapolis, IN, USA
| | - Aditya Gutta
- Division of Gastroenterology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Evan L Fogel
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indiana University Hospital, Indianapolis, IN, USA
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Guo H, Luo J, Yang H, Yang J, Bian H, Duan X, Wang X. Pediatric endoscopic retrograde pancreatography expertise in chronic pancreatitis: a single-center analysis. Front Pediatr 2025; 13:1491579. [PMID: 40007874 PMCID: PMC11850543 DOI: 10.3389/fped.2025.1491579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2024] [Accepted: 01/28/2025] [Indexed: 02/27/2025] Open
Abstract
Background and aim Chronic pancreatitis (CP) in children has exhibited an annual increase in incidence in recent years. Pediatric CP presents unique clinical features compared to adult cases. Endoscopic retrograde pancreatography (ERP) serves as a valuable and safe tool for diagnosing and treating CP in adults. However, data on endoscopic treatment of CP in children are still limited. Methods Demographics, etiology, surgical indications, diagnosis, treatment details, associated complications, and follow-up information were retrospectively studied in consecutive patients (<18 years old) who underwent ERP for CP between January 2020 and October 2024. Results A total of 17 children (7 male, 10 female) with a mean age of 10.0 ± 2.7 years were included in the study. A total of 34 endoscopic treatments were conducted. Recurrent abdominal pain was the primary clinical symptom. Imaging predominantly revealed pancreatic duct abnormalities such as tortuous dilatation and the presence of pancreatic duct stones. Notably, 41.2% (7 cases) involved genetic and congenital anatomical variations. Pancreatic duct stent placement was successfully performed in all 17 children (100.0% success rate). Stent replacements occurred on average 2.2 times (range 1-5) at intervals of 3-6 months. Postoperative pancreatitis developed in 2 cases (5.9%, 2/34), and hyperamylasemia occurred in 5 cases (14.7%, 5/34). The postprocedure visual analogue scale (VAS) score for abdominal pain significantly decreased from 6 to 1 (P < 0.001). The annual frequency of pancreatitis episodes showed a significant reduction, decreasing from 2.4 times pre-treatment to 0.6 times post-treatment (P < 0.05). Body mass index (BMI) also showed a significant improvement post-treatment compared to pre-treatment (P < 0.05). Conclusions ERP performed by trained endoscopists utilizing standard adult endoscopes and accessories proved a safe and effective treatment option for pediatric CP, with complication rates comparable to those reported in adult cases.
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Affiliation(s)
- Hongxi Guo
- Department of General Surgery, Wuhan Children’s Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, China
| | - Juan Luo
- Department of Endocrinology and Metabolism, Wuhan Children’s Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, China
| | - Hu Yang
- Department of General Surgery, Wuhan Children’s Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, China
| | - Jun Yang
- Department of General Surgery, Wuhan Children’s Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, China
| | - Hongqiang Bian
- Department of General Surgery, Wuhan Children’s Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, China
| | - Xufei Duan
- Department of General Surgery, Wuhan Children’s Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, China
| | - Xin Wang
- Department of General Surgery, Wuhan Children’s Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, China
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Mao Y, Ni J, Peng K, Yu Z, Luo S, Xia Y, Fu S, Qu Y, Xu K, Lu L, Gong X, Zhong N, Li B. Superiority of linear-array EUS over MRCP in diagnosing pancreas divisum: evidence from a multicenter retrospective study in Oriental cohorts (with video). Gastrointest Endosc 2024:S0016-5107(24)03839-2. [PMID: 39732177 DOI: 10.1016/j.gie.2024.12.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 11/11/2024] [Accepted: 12/19/2024] [Indexed: 12/30/2024]
Abstract
BACKGROUND AND AIMS Pancreas divisum (PD) is the most common developmental anatomic variant of pancreatic duct. The published data on the accuracy of the detection of PD by means of linear-array endoscopic ultrasound (L-EUS) is limited. This study aimed to assess the diagnostic accuracy of L-EUS compared with magnetic resonance cholangiopancreatography (MRCP) for identifying PD. METHODS Patients who underwent L-EUS for pancreaticobiliary indications and subsequently received endoscopic retrograde pancreatograghy (ERP) treatment were retrospectively evaluated from January 2019 to July 2023. RESULTS A total of 1378 patients from 3 tertiary centers were included, of which 120 were diagnosed with PD, as confirmed with the use of ERP, yielding an endoscopic detection rate of 8.7%. L-EUS exhibited a high sensitivity of 90.8% (95% confidence interval [CI], 85.7%-96.0%) and an overall accuracy of 99% (95% CI, 98.5%-99.5%) for the diagnosis of PD. These figures were significantly superior to those of MRCP, which showed a sensitivity of 48.4% (95% CI, 38.1%-58.6%) and an accuracy of 95.4% (95% CI, 93.5%-96.3%) (P < .001). Furthermore, the area under the receiver operating characteristic curve (AUC) for PD diagnosis was notably higher for L-EUS (95.7%) compared with MRCP (74.1%) (P < .001). Consistency testing revealed that L-EUS had an excellent kappa value of 0.934, compared with the reference standard of 0.621. Univariate logistic regression analysis identified the presence of pancreatic duct stones, chronic pancreatitis, and severe pancreatitis as potential factors leading to diagnostic failure in detecting PD with the use of L-EUS. Subsequent multivariate logistic regression analysis confirmed that the presence of pancreatic duct stones (odds ratio [OR], 5.627; 95% CI, 1.391-22.765) and severe pancreatitis (OR, 12.818; 95% CI, 2.280-72.061) were significantly associated with increased odds of L-EUS diagnostic failure for PD. CONCLUSIONS Our study conclusively demonstrates that L-EUS significantly outperforms MRCP in diagnosing PD. L-EUS exhibits markedly higher sensitivity and AUC values. However, its diagnostic reliability decreases in the presence of pancreatic duct stones or severe pancreatitis.
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Affiliation(s)
- Yuqing Mao
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai
| | - Jianbo Ni
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai; Shanghai Key Laboratory of Pancreatic Diseases, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai
| | - Kui Peng
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai
| | - Zhonggui Yu
- Department of Gastroenterology, Huizhou First Hospital, Guangzhou Province, Guangzhou
| | - Shengzheng Luo
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai
| | - Youchen Xia
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai
| | - Sengwang Fu
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai
| | - Ying Qu
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai
| | - Kai Xu
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai
| | - Lungen Lu
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai
| | - Xiaoyuan Gong
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai
| | - Ning Zhong
- Department of Gastroenterology, Qilu Hospital, Shandong University, Jinan, China.
| | - Baiwen Li
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai; Shanghai Key Laboratory of Pancreatic Diseases, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai.
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Amseian G, Ayuso JR. Pancreatic congenital anomalies and their features on CT and MR imaging: a pictorial review. Abdom Radiol (NY) 2024; 49:1734-1746. [PMID: 38478039 DOI: 10.1007/s00261-024-04229-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 01/27/2024] [Accepted: 01/29/2024] [Indexed: 05/22/2024]
Abstract
OBJECTIVE To review the congenital anomalies of the pancreas with their main clinical manifestations and key imaging findings on CT and MRI. BACKGROUND AND CLINICAL SIGNIFICANCE Anomalies of pancreatic development are frequent and generally asymptomatic, but can mimic and predispose individuals to pancreatic or peripancreatic pathologies, such as pancreatitis or malignancy. Their correct diagnosis may help avoid unnecessary further investigations and procedures, or establish adequate treatment when they manifest clinically. Differentiating pancreatic congenital anomalies from their main radiological mimics constitutes a challenge for the radiologist and requires familiarity with key imaging findings. CONCLUSION The imaging findings of CT and MRI are essential for the correct diagnosis of congenital pancreatic anomalies.
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Affiliation(s)
- Gary Amseian
- Department of Radiology, Barcelona Hospital Clínic, Barcelona, Spain.
| | - Juan-Ramón Ayuso
- Department of Radiology, Barcelona Hospital Clínic, Barcelona, Spain
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Goda Y, Irie K, Anan H, Suzuki Y, Ikeda A, Ikeda R, Kaneko H, Sue S, Miwa H, Maeda S. The usefulness of texture and color enhancement imaging to identify the minor papilla orifice. DEN OPEN 2024; 4:e358. [PMID: 38586252 PMCID: PMC10995446 DOI: 10.1002/deo2.358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 03/10/2024] [Accepted: 03/19/2024] [Indexed: 04/09/2024]
Abstract
In clinical cases of pancreas divisum, endoscopic retrograde cholangiopancreatography often necessitates cannulation of the pancreatic duct through the minor papilla. Nevertheless, this procedure can be challenging because of the small size of the minor papilla and the difficulty in visualizing the ductal orifice. A new image-enhanced endoscopy technique called texture and color enhancement imaging (TXI) has been developed, which enhances texture, brightness, and color compared with white-light imaging, resulting in subtle differences in the surface mucosa. Herein, we describe the case of a 73-year-old man with pancreas divisum in whom TXI was useful in identifying the orifice of the minor papilla. He was referred to our hospital with repetitive acute exacerbation of chronic pancreatitis. Since contrast-enhanced computed tomography revealed a pancreatic stone in the main pancreatic duct, endoscopic retrograde cholangoepancreatography was performed as a therapeutic intervention. Despite the initial difficulty in identifying the orifice of the minor papilla on white-light imaging, TXI enhanced its visibility successfully, enabling dorsal pancreatic duct cannulation via the minor papilla. Subsequently, endoscopic pancreatic sphincterotomy was performed and a 6Fr plastic stent was placed. Post-endoscopic therapy, the patient's abdominal pain was relieved. TXI was useful in identifying the minor papilla orifice and led to successful cannulation.
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Affiliation(s)
- Yoshihiro Goda
- Division of GastroenterologyYokohama City University School of Medicine Graduate School of MedicineKanagawaJapan
| | - Kuniyasu Irie
- Division of GastroenterologyYokohama City University School of Medicine Graduate School of MedicineKanagawaJapan
| | - Hideyuki Anan
- Division of GastroenterologyYokohama City University School of Medicine Graduate School of MedicineKanagawaJapan
| | - Yuichi Suzuki
- Division of GastroenterologyYokohama City University School of Medicine Graduate School of MedicineKanagawaJapan
| | - Aya Ikeda
- Division of GastroenterologyYokohama City University School of Medicine Graduate School of MedicineKanagawaJapan
| | - Ryosuke Ikeda
- Division of GastroenterologyYokohama City University School of Medicine Graduate School of MedicineKanagawaJapan
| | - Hiroaki Kaneko
- Division of GastroenterologyYokohama City University School of Medicine Graduate School of MedicineKanagawaJapan
| | - Soichiro Sue
- Division of GastroenterologyYokohama City University School of Medicine Graduate School of MedicineKanagawaJapan
| | - Haruo Miwa
- Gastroenterological CenterYokohama City University Medical CenterKanagawaJapan
| | - Shin Maeda
- Division of GastroenterologyYokohama City University School of Medicine Graduate School of MedicineKanagawaJapan
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Schepis T, Pafundi PC, Tringali A, Carcagnì A, Familiari P, Landi R, Boskoski I, Perri V, Spada C, Costamagna G. Endoscopic minor papilla sphincterotomy in patients with complete pancreas divisum and acute recurrent pancreatitis: a metanalysis. Scand J Gastroenterol 2024; 59:225-231. [PMID: 37795553 DOI: 10.1080/00365521.2023.2266079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 09/22/2023] [Accepted: 09/28/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND AND AIMS Pancreas divisum (PD) is a congenital variant of the pancreatic ductal system and a potential cause of acute recurrent pancreatitis (ARP). Endoscopic minor papilla sphincterotomy (MiES) is the most common procedure performed in the management of PD-related ARP. The aim of this study is to perform a meta-analysis estimating the efficacy and the safety of MiES in the management of patients with PD-related ARP. METHODS A research was performed in Pubmed, EMBASE and Web of science, the studies were reviewed and selected according to inclusion and exclusion criteria. Evaluation of Heterogeneity and publication bias was performed, and a random effect model was used to estimate the effect size of each study. RESULTS One hundred and thirteen articles were selected and reviewed, 13 met the inclusion criteria. All the studies were retrospective with a mean follow-up duration of 45.9 months. A total of 323 patients with PD-related ARP treated with MiES were included in the meta-analysis. The overall clinical success rate of MiES (defined as no further episodes of ARP, reduction of episodes of ARP, or improvement in quality of life) was of 77% (95%CI: 72%-81%; p = 0.30). Evaluating only the studies with clinical success rate defined as "no further AP in the follow-up" the clinical success rate was of 69.8% (95%CI: 61.3%-77.2%; p = 0.57), while evaluating the studies with other definitions (reduction of episodes of ARP or improvement in quality of life) the clinical success rate was of 81.2% (95%CI: 75.2%-86.1%; p = 0.45). The common fixed effects model disclosed a 25.5% overall adverse events rate (95%CI: 19.3%-32.8%; p = 0.42): acute pancreatitis in 14.3% (95%CI: 9.7%-20.6%; p = 0.36), bleeding in 5.6% (95%CI: 2.9%-10.4%; p = 0.98), and other adverse events in 5.6% (95%CI: 2.9%-10.4%; p = 0.67). CONCLUSION MiES is an effective and relatively safe treatment in the management of PD-related ARP. The retrospective nature of the studies selected is the main limitations of this metanalysis. Prospective trials are needed to confirm these data.
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Affiliation(s)
- T Schepis
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
| | - P C Pafundi
- Facility of Epidemiology and Biostatistics, Gemelli Generator, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - A Tringali
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
| | - A Carcagnì
- Facility of Epidemiology and Biostatistics, Gemelli Generator, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - P Familiari
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
| | - R Landi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
| | - I Boskoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
| | - V Perri
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
| | - C Spada
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
| | - G Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
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Chatterjee A, Rana SS. Endoscopic Ultrasound in Pancreatic Duct Anomalies. Diagnostics (Basel) 2023; 13:3129. [PMID: 37835872 PMCID: PMC10572994 DOI: 10.3390/diagnostics13193129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 09/26/2023] [Accepted: 10/03/2023] [Indexed: 10/15/2023] Open
Abstract
Embryological development of the pancreas is a complex phenomenon and, therefore, it can have multiple developmental aberrations. Fortunately, the majority of these pancreatic ductal anomalies are asymptomatic with no clinical relevance and are incidentally detected during diagnostic cross-sectional imaging or endoscopic retrograde cholangiopancreatography (ERCP) or autopsy. Occasionally, pancreatic duct anomalies can result in symptoms like abdominal pain or recurrent pancreatitis. Also, an accurate pre-operative diagnosis of ductal anomalies can prevent inadvertent duct injury during surgery. Conventionally, ERCP had been used for an accurate diagnosis of pancreatic duct anomalies. However, because it is invasive and associated with a risk of pancreatitis, it has been replaced with magnetic resonance cholangiopancreatography (MRCP). MRCP has demonstrated high sensitivity and specificity for the diagnosis of ductal anomalies, which can be further improved with the use of secretin-enhanced MRCP. Endoscopic ultrasound (EUS) is a new diagnostic and interventional tool in the armamentarium of endoscopists and has demonstrated promising results in the detection of pancreatic duct variations and anomalies. Along with the visualization of the course and configuration of the pancreatic duct, EUS can also visualize changes in the pancreatic parenchyma, thereby helping with an early diagnosis of any co-existent pancreatic disease. Absence of the stack sign and crossed duct sign are important EUS features to diagnose pancreas divisum. EUS can also help with the diagnosis of other congenital ductal anomalies like annular pancreas, ansa pancreatica, and anomalous pancreaticobiliary union, although the published experience is limited.
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Affiliation(s)
| | - Surinder Singh Rana
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh 160012, India;
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10
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Inamdar S, Cote GA, Yadav D. Endotherapy for Pancreas Divisum. Gastrointest Endosc Clin N Am 2023; 33:789-805. [PMID: 37709411 DOI: 10.1016/j.giec.2023.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
Pancreas divisum (PD) is a common anatomic variant of the pancreatic duct. Causal association between PD and pancreatitis has been debated for many years. Minor papilla sphincterotomy (miES) is offered in clinical practice to patients with idiopathic acute recurrent pancreatitis (iRAP) and PD. However, available data originate mainly from observational studies with many limitations. An ongoing international, multicenter, sham-controlled trial is evaluating the efficacy of miES in iRAP and PD. Endoscopic therapy for pain relief has limited to no benefit in patients with chronic abdominal pain or chronic pancreatitis who have PD and is not recommended.
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Affiliation(s)
- Sumant Inamdar
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Arkansas for Medical Sciences, Shorey Building, 8th Floor, 4301 West Markham Street, Little Rock, AR 72205, USA.
| | - Gregory A Cote
- Division of Gastroenterology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Mail Code L461, Portland, OR, USA
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburg Medical Center, 200 Lothrop Street, M2, C-wing, Pittsburgh, PA 15213, USA
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11
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Chen K, Lin Y, Yen H, Chen Y, Shih K. Endoscopic management in a patient with pancreas divisum and recurrent pancreatitis: A case report of endoscopic ultrasound‐guided rendezvous technique. ADVANCES IN DIGESTIVE MEDICINE 2022. [DOI: 10.1002/aid2.13299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Kuei‐Yu Chen
- Endoscopy Center, Division of Gastroenterology Changhua Christian Hospital Changhua Taiwan
| | - Yen‐Chih Lin
- Endoscopy Center, Division of Gastroenterology Changhua Christian Hospital Changhua Taiwan
| | - Hsu‐Heng Yen
- Endoscopy Center, Division of Gastroenterology Changhua Christian Hospital Changhua Taiwan
| | - Yang‐Yuan Chen
- Endoscopy Center, Division of Gastroenterology Changhua Christian Hospital Changhua Taiwan
| | - Kai‐Lun Shih
- Endoscopy Center, Division of Gastroenterology Changhua Christian Hospital Changhua Taiwan
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Mann R, Boregowda U, Vyas N, Gajendran M, Umapathy CP, Sayana H, Echavarria J, Patel S, Saligram S. Current advances in the management of chronic pancreatitis. Dis Mon 2021; 67:101225. [PMID: 34176572 DOI: 10.1016/j.disamonth.2021.101225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Chronic pancreatitis is characterized by irreversible destruction of pancreatic parenchyma and its ductal system resulting from longstanding inflammation, leading to fibrosis and scarring due to genetic, environmental, and other risk factors. The diagnosis of chronic pancreatitis is made based on a combination of clinical features and characteristic findings on computed tomography or magnetic resonance imaging. Abdominal pain is the most common symptom of chronic pancreatitis. The main aim of treatment is to relieve symptoms, prevent disease progression, and manage complications related to chronic pancreatitis. Patients who do not respond to medical treatment or not a candidate for surgical treatment are usually managed with endoscopic therapies. Endoscopic therapies help with symptoms such as abdominal pain and jaundice by decompression of pancreatic and biliary ducts. This review summarizes the risk factors, pathophysiology, diagnostic evaluation, endoscopic treatment of chronic pancreatitis, and complications. We have also reviewed recent advances in endoscopic retrograde cholangiopancreatography and endoscopic ultrasound-guided therapies for pancreatic duct obstruction due to stones, strictures, pancreatic divisum, and biliary strictures.
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Affiliation(s)
- Rupinder Mann
- Department of Internal Medicine, Saint Agnes Medical Center, 1303 E Herndon Ave, Fresno, CA 93720, USA
| | - Umesha Boregowda
- Department of Internal Medicine, Bassett Healthcare Network, Columbia Bassett Medical School, 1 Atwell Road, Cooperstown, NY 13326, USA
| | - Neil Vyas
- Department of Gastroenterology and Advanced endoscopy, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Mahesh Gajendran
- Department of Internal Medicine, Texas Tech University Health Science Center El Paso, 2000B Transmountain Road, El Paso, TX 79911, USA
| | - Chandra Prakash Umapathy
- Department of Gastroenterology and Advanced endoscopy, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Hari Sayana
- Department of Gastroenterology and Advanced endoscopy, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Juan Echavarria
- Department of Gastroenterology and Advanced endoscopy, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Sandeep Patel
- Department of Gastroenterology and Advanced endoscopy, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Shreyas Saligram
- Department of Gastroenterology and Advanced endoscopy, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA.
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Liu K, Liu X, Shi C, Liu S, Du H, Li Y, Wang N, Feng Z, Jiang H. Double plastic stent implantation for recurrent acute pancreatitis with incomplete pancreas divisum: a case report and literature review. J Int Med Res 2021; 49:3000605211060142. [PMID: 34842463 PMCID: PMC8647234 DOI: 10.1177/03000605211060142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Pancreas divisum (PD) is a common pancreatic malformation caused by the failure of fusion between ventral and dorsal pancreatic ducts. There is a small branch of communication between the two systems in incomplete PD, and this variation has an incidence of 15%. A 43-year-old female patient presented to our department with recurrent abdominal pain. Magnetic resonance cholangiopancreatography (MRCP) showed that the ventral pancreatic duct was curved, with a local pouchlike dilatation. Endoscopic ultrasonography supported the diagnosis of incomplete PD and showed a thin branch of communication between ventral and dorsal pancreatic ducts. Endoscopic retrograde cholangiopancreatography (ERCP) and papillotomy of the minor papilla with double plastic stent implantation were performed. One pancreatic plastic stent was inserted across the minor and major papilla over the guide wire, creating a U-shape. The other wire-guided plastic stent was inserted through the minor papilla into the dorsal pancreatic duct. The pancreatic fluid drained smoothly after stent placement. During the 6-month follow-up, the patient remained well, without recurrence of pancreatitis.
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Affiliation(s)
- Kunyi Liu
- Department of Gastroenterology, Hebei Key Laboratory of Gastroenterology, Hebei Institute of Gastroenterology, 71213Second Hospital of Hebei Medical University, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China
| | - Xuechen Liu
- Department of Gastroenterology, Hebei Key Laboratory of Gastroenterology, Hebei Institute of Gastroenterology, 71213Second Hospital of Hebei Medical University, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China
| | - Chengyi Shi
- Department of Gastroenterology, Hebei Key Laboratory of Gastroenterology, Hebei Institute of Gastroenterology, 71213Second Hospital of Hebei Medical University, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China
| | - Siqi Liu
- Department of Gastroenterology, Hebei Key Laboratory of Gastroenterology, Hebei Institute of Gastroenterology, 71213Second Hospital of Hebei Medical University, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China
| | - Hongwei Du
- Department of Gastroenterology, Hebei Key Laboratory of Gastroenterology, Hebei Institute of Gastroenterology, 71213Second Hospital of Hebei Medical University, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China
| | - Yan Li
- Department of Gastroenterology, Hebei Key Laboratory of Gastroenterology, Hebei Institute of Gastroenterology, 71213Second Hospital of Hebei Medical University, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China
| | - Na Wang
- Department of Gastroenterology, Hebei Key Laboratory of Gastroenterology, Hebei Institute of Gastroenterology, 71213Second Hospital of Hebei Medical University, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China
| | - Zhijie Feng
- Department of Gastroenterology, Hebei Key Laboratory of Gastroenterology, Hebei Institute of Gastroenterology, 71213Second Hospital of Hebei Medical University, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China
| | - Huiqing Jiang
- Department of Gastroenterology, Hebei Key Laboratory of Gastroenterology, Hebei Institute of Gastroenterology, 71213Second Hospital of Hebei Medical University, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China
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de Jong DM, Stassen PM, Poley JW, Fockens P, Timmer R, Voermans RP, Verdonk RC, Bruno MJ, de Jonge PJ. Clinical outcome of endoscopic therapy in patients with symptomatic pancreas divisum: a Dutch cohort study. Endosc Int Open 2021; 9:E1164-E1170. [PMID: 34222643 PMCID: PMC8216775 DOI: 10.1055/a-1460-7899] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 02/15/2021] [Indexed: 10/28/2022] Open
Abstract
Background and study aims Although the majority of patients with pancreas divisum (PDiv) are asymptomatic, a subgroup present with recurrent pancreatitis or pain for which endoscopic therapy may be indicated. The aim of this study was to evaluate success rates and long-term outcomes of endoscopic treatment in patients with symptomatic PDiv. Patients and methods A multicenter, retrospective cohort study was performed. Patients with symptomatic PDiv presenting with recurrent acute pancreatitis (RAP), chronic pancreatitis (CP), or chronic abdominal pancreatic-type pain (CAP) who underwent endoscopic retrograde cholangiopancreatography (ERCP) between January 2000 and December 2019 were included. The primary outcome was clinical success, defined as either no recurrent episode of acute pancreatitis (AP) for RAP patients, no flares for CP patients, or absence of abdominal pain for patients with CAP after technically successful ERCP. Results In 60 of 81 patients (74.1 %) a technically successful papilla minor intervention was performed. Adverse events were reported in 30 patients (37 %), with post-ERCP pancreatitis in 18 patients. The clinical success rate for patients with at least 3 months of follow-up was 42.6 %, with higher rates of success among patients presenting with RAP (44.4 %) as compared to those with CP (33.3 %) or CAP (33.3 %). Long-term sustained response was present in 40.9 % of patients with a technically successful intervention. In patients with RAP who did not completely respond to treatment, the mean number of AP episodes after treatment decreased significantly from 3.5 to 1.1 per year, and subsequently the interval between AP episodes increased from 278 to 690 days ( P = 0.0006). A potential predictive factor of failure of clinical success after technically successful ERCP, at univariate analysis, was male sex (OR = 0.25, P = 0.02). Conclusions Endoscopic therapy in patients with symptomatic PDiv is moderately effective, with its highest yield in patients presenting with RAP. Future studies are needed to assess factors predictive for success of endoscopic therapy and potential risk factors for relapse after ERCP.
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Affiliation(s)
- David M. de Jong
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Pauline M. Stassen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Jan Werner Poley
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, the Netherlands
| | - Robin Timmer
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Rogier P. Voermans
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, the Netherlands
| | - Robert C. Verdonk
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Marco J. Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Pieter J.F. de Jonge
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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Pancreas Divisum Increases the Risk of Recurrent Acute Pancreatitis in Patients with rs12338 Polymorphism in the Cathepsin B Gene. Dig Dis Sci 2021; 66:2283-2290. [PMID: 32754840 DOI: 10.1007/s10620-020-06517-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 07/22/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Pancreas divisum (PD) as a cause of pancreatitis has been debated. In this study, we report the association of multiple gene polymorphisms on the risk of RAP in the presence of PD. DESIGN We enrolled 687 individuals (167 IRAP, 276 ICP, and 244 unrelated healthy controls) from May 2015 to September 2016. Patients were divided into those with/without PD. Associations between the significantly prevalent SNPs and IRAP/ICP in the presence of PD were evaluated. Clinical data were analyzed using Mann-Whitney U/Chi-square test. Effect size of association of SNPs with IRAP/ICP was expressed as odds ratio (OR) (95% CI). Gene-gene interaction was assessed by transheterozygosity analyses. Bonferroni-corrected two-tailed "p" value of ≤ 0.01 was considered statistically significant. RESULTS Thirty-three (19.8%) and 82 (29.7%) patients with IRAP and ICP, respectively, had PD. Among the patients with IRAP, duration of disease was significantly shorter in those with PD compared to those without (mean [95% CI] duration: 1.6 (1.3-1.9) vs 2.7 (2.3-3.1) years; p = 0.005). There were no differences in gender, race, and diabetes among patients with/without PD in IRAP/ICP groups. Mean (95% CI) pancreatic duct diameter (mm) was significantly higher in the presence of PD in patients with both IRAP [1.6 (1.4-1.9) v/s 1.29 (1.2-1.4); p = 0.03)] and ICP [5.2 (4.5-5.9) v/s 4.5 (3.9-5.1); p = 0.02]. CTSB (rs12338) polymorphisms were significantly associated with IRAP [OR (95% CI) 2.44 (1.41-4.22); p = 0.001] among patients with PD. No association was observed with ICP. Transheterozygosity analysis did not show any significant associations of combination of SNPs with IRAP in the presence of PD. CONCLUSION Risk of RAP due to PD increases in patients with rs12338 polymorphism in the cathepsin B gene.
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Swensson J, Zaheer A, Conwell D, Sandrasegaran K, Manfredi R, Tirkes T. Secretin-Enhanced MRCP: How and Why- AJR Expert Panel Narrative Review. AJR Am J Roentgenol 2021; 216:1139-1149. [PMID: 33263419 PMCID: PMC8068672 DOI: 10.2214/ajr.20.24857] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Secretin-enhanced MRCP (S-MRCP) has advantages over standard MRCP for imaging of the pancreaticobiliary tree. Through the use of secretin to induce fluid production from the pancreas and leveraging of fluid-sensitive MRCP sequences, S-MRCP facilitates visualization of ductal anatomy, and the findings provide insight into pancreatic function, allowing radiologists to provide additional insight into a range of pancreatic conditions. This narrative review provides detailed information on the practical implementation of S-MRCP, including patient preparation, logistics of secretin administration, and dynamic secretin-enhanced MRCP acquisition. Also discussed are radiologists' interpretation and reporting of S-MRCP examinations, including assessments of dynamic compliance of the main pancreatic duct and of duodenal fluid volume. Established indications for S-MRCP include pancreas divisum, anomalous pancreaticobiliary junction, Santorinicele, Wirsungocele, chronic pancreatitis, main pancreatic duct stenosis, and assessment of complex postoperative anatomy. Equivocal or controversial indications are also described along with an approach to such indications. These indications include acute and recurrent acute pancreatitis, pancreatic exocrine function, sphincter of Oddi dysfunction, and pancreatic neoplasms.
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Affiliation(s)
- Jordan Swensson
- Department of Radiology, Indiana University, Indianapolis, IN, USA
| | - Atif Zaheer
- Pancreatitis Center, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA; Division of Abdominal Imaging, Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Darwin Conwell
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - Riccardo Manfredi
- Department of Diagnostic Imaging, Oncological Radiotherapy, and Hematology - Diagnostic Imaging Area, Italy; Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy
| | - Temel Tirkes
- Department of Radiology, Indiana University, Indianapolis, IN, USA
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Pancreaticobiliary maljunction in Turkish patients: a multicenter case series. Surg Endosc 2021; 36:2042-2051. [PMID: 33844087 DOI: 10.1007/s00464-021-08490-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 03/28/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND AIMS Pancreaticobiliary maljunction (PBM) is a malformation in which the pancreatic and bile ducts join outside the duodenal wall. It is associated with various biliary and pancreatic diseases. In addition, patients with PBM carry a substantial lifetime risk of developing biliary or gallbladder carcinoma. We aimed to present a multicenter case series of PBM from Turkey. METHODS This study was conducted in adult and pediatric PBM patients who were referred to three tertiary reference centers of Turkey for endoscopic retrograde cholangiopancreatography (ERCP) between July 2007 and May 2020. The clinical presentations, types of PBM, ERCP findings, surgical histories, and the postoperative courses, including the development of biliary malignancies, were retrospectively reviewed. RESULTS The study group included 47 (31 adult and 16 children) patients. Type D PBM was more frequent (13/41: 27.7%) than that reported in Eastern studies. Type A PBM was more common in the adults (51.6% vs. 12.5%, p < 0.05), whereas type C was more common in pediatric patients (31.3% vs. 13.2%, p < 0.05). Although fusiform anatomy was predominant in both of the groups, cystic dilatation was more common (25.8% vs. 12.5%) in adults and the common bile duct diameter was greater [22 mm (range 11-58) vs. 12 mm (range 5-33)] in adult patients compared to pediatric patients. Resective surgeries were more frequently done in pediatric patients (73.3% vs. 53.6%), whereas cholecystectomy was more frequently performed in adult patients (21.4% vs. 6.7%). CONCLUSION Although our findings were compatible with Eastern studies, type D PBM (associated with pancreas divisum) was more frequent in our study population.
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Evrimler S, Swensson JK, Soufi M, Tirkes T, Schmidt CM, Akisik F. Wirsungocele: evaluation by MRCP and clinical significance. Abdom Radiol (NY) 2021; 46:616-622. [PMID: 32737547 DOI: 10.1007/s00261-020-02675-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/14/2020] [Accepted: 07/18/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE Wirsungocele is a rare cystic dilatation of the main pancreatic duct seen at the terminal portion of the duct of Wirsung. The purpose of our study is to evaluate the diagnostic value of MRCP in detection of Wirsungocele and the association between the MRCP-determined size of Wirsungocele and the MRCP-clinical findings of pancreatitis. METHODS Thirty-four patients with reported 'Wirsungocele' were analyzed in the study. Two radiologists reviewed MRCP/S-MRCP images for the presence and diameter of Wirsungocele (WD), main pancreatic duct dilatation (MPDD), side branch ectasia (SBE), acinarization, and duodenal filling grade. Electronic medical record review included symptoms (abdominal pain), signs (recurrent acute/chronic pancreatitis), and select laboratory testing (serum amylase and lipase). Inter-reader agreement values were calculated by ICC. Pearson correlation analysis was performed to evaluate the association of WD with radiological and clinical findings. The comparison of WD on MRCP versus S-MRCP was calculated by Wilcoxon test. Mann-Whitney U test was used for two independent variable comparisons. RESULTS The sensitivity of MRCP for the detection of Wirsungocele calculated using the S-MRCP and ERCP as the reference method was 76.9% and 100%, respectively. There was a significant difference in the diameter of Wirsungocele measured by MRCP vs S-MRCP (p < 0.001). There was good inter-reader agreement for the detection of Wirsungocele on MRCP and measurement of WD on MRCP and S-MRCP (ICC: 0.79, 0.89, and 0.80, respectively, p < 0.001). There was a significant difference in WD between the patients with and without MPDD (p < 0.05). There was a significant positive correlation between WD and MPDD (r = 0.66, p < 0.05). WD was significantly associated with recurrent acute pancreatitis (p < 0.05). CONCLUSION MRCP is a highly sensitive and non-invasive imaging tool for detection of Wirsungocele. Greater Wirsungocele diameter is associated with MPDD and recurrent acute pancreatitis.
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Affiliation(s)
- Sehnaz Evrimler
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, 550 N University Blvd Room 0663, Indianapolis, IN, 46202, USA
- Department of Radiology, Suleyman Demirel University School of Medicine, East Campus, Cunur, 32260, Isparta, Turkey
| | - Jordan K Swensson
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, 550 N University Blvd Room 0663, Indianapolis, IN, 46202, USA
| | - Mazhar Soufi
- Department of Surgery, Indiana University School of Medicine, 550 N University Blvd Suite 1295, Indianapolis, IN, 46202, USA
| | - Temel Tirkes
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, 550 N University Blvd Room 0663, Indianapolis, IN, 46202, USA
| | - C Max Schmidt
- Department of Surgery, Indiana University School of Medicine, 550 N University Blvd Suite 1295, Indianapolis, IN, 46202, USA
| | - Fatih Akisik
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, 550 N University Blvd Room 0663, Indianapolis, IN, 46202, USA.
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Clinical Outcomes Following Therapeutic Endoscopic Retrograde Cholangiopancreatography in Children With Pancreas Divisum. J Pediatr Gastroenterol Nutr 2021; 72:300-305. [PMID: 33230075 DOI: 10.1097/mpg.0000000000002996] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Pancreas divisum (PD) is a risk factor in children for the development of acute pancreatitis. Endoscopic retrograde cholangiopancreatography (ERCP) with minor papilla endoscopic sphincterotomy (mPES) may be of clinical benefit, however, the clinical outcomes from endotherapy remain unclear. We sought to review the outcomes and safety of therapeutic ERCP in children with PD. METHODS We performed a retrospective chart of children with PD who underwent an ERCP between February 2012 and December 2018. Pertinent patient, clinical and procedure information was collected including procedure-related adverse events. A follow-up questionnaire of the parent was conducted to determine the clinical impact from endotherapy. RESULTS Fifty-eight ERCPs were performed in 27 patients (14 boys; mean age: 9.7 years, range 2-19) with PD. All patients underwent a successful mPES. A genetic variant was identified in 19/26 (73%) tested patients. Post-ERCP pancreatitis (PEP) was the only observed adverse event; 21% (12/58). Median follow-up interval from first ERCP intervention to questionnaire completion was 31.5 months (range: 4--72 months). Of the 20 questionnaire responders, 13 reported clinical improvement from endotherapy. CONCLUSIONS The majority of children from our PD cohort possessed at least 1 genetic variant. Most questionnaire responders had a favorable response to endotherapy. PEP rate was comparable with that of prior reports in adult patients.
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Pan G, Yang K, Gong B, Deng Z. Analysis of the Efficacy and Safety of Endoscopic Retrograde Cholangiopancreatography in Children With Symptomatic Pancreas Divisum. Front Pediatr 2021; 9:761331. [PMID: 34796156 PMCID: PMC8592933 DOI: 10.3389/fped.2021.761331] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 10/12/2021] [Indexed: 12/11/2022] Open
Abstract
Background: Endoscopic retrograde cholangiopancreatography (ERCP) has been increasingly performed in children with symptomatic pancreas divisum (PD). Aim: To investigate the safety and efficacy of ERCP in the treatment of children with symptomatic PD. Methods: We performed a retrospective analysis on children with PD who were treated with ERCP at Shanghai Children's Medical Center between June 2015 and May 2020. Pertinent patient, clinical and procedural data were collected to assess the therapeutic effects and identify the risk factors for post-ERCP pancreatitis (PEP). Results: Overall, 114 ERCPs were performed in 46 children with PD. With a median follow-up of 28.5 months (12-71 months), 40 (87.0%) children achieved clinical remission, the median number of acute pancreatitis episodes decreased from four times per year pre-operatively to once per year post-operatively (P < 0.001), and the nutritional score improved post-operatively (P = 0.004). The incidence of PEP was 7.9%, and female sex, stone extraction, and gene mutations were identified as possible risk factors for PEP on univariate analysis. However, there was no statistical significance on multivariate analysis (P > 0.05). Conclusion: Therapeutic ERCP is an effective and safe intervention for children with symptomatic PD.
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Affiliation(s)
- Guixian Pan
- Department of Gastroenterology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Kaihua Yang
- Department of Gastroenterology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Biao Gong
- Department of Gastroenterology, Shanghai Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Zhaohui Deng
- Department of Gastroenterology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Meng QQ, Zhao SB, Wang ZJ, Shen Z, Xia T, Wang SL, Gu L, Pan P, Li ZS, Yao J, Shi YH, Bai Y. Incidence and risk factors for post-ERCP pancreatitis in pancreas divisum patients without chronic pancreatitis. Scand J Gastroenterol 2020; 55:732-736. [PMID: 32567400 DOI: 10.1080/00365521.2020.1774922] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Aims: The studies on post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in pancreas divisum (PD) patients without chronic pancreatitis (CP) are rare. In this study, we aimed to evaluate the incidence of PEP in PD patients without CP and the risk and protective factors for PEP.Methods: Consecutive patients with symptomatic PD that underwent ERCP from January 2005 to December 2017 were retrospectively analyzed. The patients were divided into PD without CP group and CP group. The basic information and medical records of patients were collected. The risk and protective factors for PEP in PD patients without CP were analyzed by univariate logistic analysis.Results: A total of 89 ERCP procedures were performed in 51 PD patients without CP, and 249 procedures in 136 patients with CP. The incidence of PEP was significantly higher in PD patients without CP than those with CP (15.7% vs. 5.6%, p = .005). Female gender were independent risk factors for PEP, while dorsal duct stent placement was a protective factor.Conclusion: CP may be a protective factor against PEP in PD patients. Female was a risk factor for PEP in PD patients and dorsal duct stent placement was a preventive factor that reduced the incidence of PEP in PD patients without CP.
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Affiliation(s)
- Qian-Qian Meng
- Digestive Endoscopy Center, Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Sheng-Bing Zhao
- Digestive Endoscopy Center, Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Zhi-Jie Wang
- Digestive Endoscopy Center, Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Zhen Shen
- Digestive Endoscopy Center, Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Tian Xia
- Digestive Endoscopy Center, Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Shu-Ling Wang
- Digestive Endoscopy Center, Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Lun Gu
- Digestive Endoscopy Center, Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Peng Pan
- Digestive Endoscopy Center, Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Zhao-Shen Li
- Digestive Endoscopy Center, Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Jun Yao
- Department of Gastroenterology, The Second Clinical Medical College, Jinan University, Shenzhen, China
| | - Yi-Hai Shi
- Department of Gastroenterology, Gongli Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Yu Bai
- Digestive Endoscopy Center, Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
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Identifying Factors Predicting Response to Endoscopic Management of Chronic Pancreatitis Secondary to Pancreas Divisum. J Gastrointest Surg 2020; 24:585-589. [PMID: 30887289 DOI: 10.1007/s11605-019-04122-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 01/13/2019] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Appropriately selecting patients with chronic pancreatitis associated with pancreas divisum (PD) for endoscopic retrograde cholangiopancreatography (ERCP)-based therapy versus surgery remains difficult. The objective of this study was to identify factors that predict success or failure of ERCP for treatment of chronic pancreatitis in PD. METHODS Patients undergoing ERCP for a diagnosis of PD and pancreatitis between 2008 and 2016 were identified and grouped according to whether they required one or two ERCPs or three or more ERCPs. Groups were compared along demographic, diagnostic, laboratory, ERCP-related, and outcome variables. RESULTS Patients requiring 1-2 ERCPs were less likely to have back pain on initial presentation (4 vs. 24%, p = 0.02) and less likely to have a dilated bile duct on imaging prior to their first ERCP (8 vs. 30%, p = 0.04) than those requiring 3+ ERCPs. Patients requiring 1-2 ERCPs were also less likely to eventually require operative intervention for treatment of their chronic pancreatitis than those requiring 3+ ERCPs (24 vs. 44%, p = 0.047). On multivariable analysis, a dilated bile duct (odds ratio (OR) = 6.0, 95% confidence interval (CI) = 1.01-36.0, p = 0.048) was independently associated with requiring 3+ ERCPs. Back pain (OR = 6.3, 95% CI = 0.73-54.2, p = 0.09) trended toward but did not reach statistical significance for being independently associated with requiring 3+ ERCPs. CONCLUSIONS The success of endoscopic treatment of chronic pancreatitis in patients with PD is dependent on proper patient selection. Patients with a dilated bile duct and back pain upon presentation may not respond well to endoscopic treatment alone and are more likely to eventually require operative intervention. Consideration should be given to early operative intervention in these patients.
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Cicero G, Blandino A, Ascenti G, Mazziotti S. Separate pancreatic ducts draining into a type IV choledochal cyst: simultaneous anatomical variants in a child suffering from cholelithiasis and acute pancreatitis. Surg Radiol Anat 2019; 42:449-452. [PMID: 31707433 DOI: 10.1007/s00276-019-02377-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 10/26/2019] [Indexed: 01/16/2023]
Abstract
The biliary tree and the pancreatic ducts originate from different buds of the primitive foregut. A plethora of anatomical variants and congenital anomalies have been described for both the biliary and the pancreatic duct systems, although they are usually asymptomatic. However, in some cases, these abnormalities can lead to serious clinical scenarios, especially when involving the biliopancreatic junction, with consequent mixing and reflux of the two different juices. To the best of our knowledge, we present the first case of pancreas divisum ducts draining into a choledochal cyst, with the lower third of the choledochus configuring a common biliopancreatic duct, in a child suffering from cholelithiasis and acute pancreatitis.
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Affiliation(s)
- Giuseppe Cicero
- Section of Radiological Sciences, Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Policlinico "G. Martino" Via Consolare Valeria 1, 98100, Messina, Italy.
| | - Alfredo Blandino
- Section of Radiological Sciences, Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Policlinico "G. Martino" Via Consolare Valeria 1, 98100, Messina, Italy
| | - Giorgio Ascenti
- Section of Radiological Sciences, Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Policlinico "G. Martino" Via Consolare Valeria 1, 98100, Messina, Italy
| | - Silvio Mazziotti
- Section of Radiological Sciences, Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Policlinico "G. Martino" Via Consolare Valeria 1, 98100, Messina, Italy
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Abstract
Introduction: Pancreas divisum is the most common congenital malformation of the pancreas with the majority asymptomatic. The etiological role, pathogenesis, clinical significance and management of pancreas divisum in pancreatic disease has not been clearly defined and our understanding is yet to be fully elucidated.Areas covered: This review describes the role of pancreas divisum in the development of pancreatic disease and the ambiguity related to it. In our attempt to offer clarity, a comprehensive search on PubMed, Ovid, Embase and Cochrane Library from inception to May 2019 was undertaken using key words "pancreas divisum", "idiopathic recurrent acute pancreatitis" and "chronic pancreatitis".Expert opinion: Current research fails to define a clear association between pancreas divisum and pancreatic disease. Though debatable, several studies do suggest a pathological role of pancreas divisum in pancreatic disease and a benefit of minor papilla therapy in the setting of acute recurrent pancreatitis. Surgical and endoscopic therapeutic modalities have not been directly compared. With the current data available, it would be imprudent to advise a definitive line of management for pancreatic disease associated with pancreas divisum and should involve a comprehensive discussion with the individual patient to define expectations before embarking on any medical and/or interventional therapy.
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Affiliation(s)
- Aditya Gutta
- Advanced Endoscopy Gastroenterology Fellow, Indiana University School of Medicine, Division of Gastroenterology, 550 N. University Blvd, Indianapolis, IN 46202
| | - Evan Fogel
- Professor of Medicine, Indiana University School of Medicine, Division of Gastroenterology, 550 N. University Blvd, Suite 1602, Indianapolis, IN 46202
| | - Stuart Sherman
- Professor of Medicine, Glen Lehman Professor in Gastroenterology, Indiana University School of Medicine, Division of Gastroenterology, 550 N. University Blvd, Suite 1634, Indianapolis, IN 46202
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Abstract
OBJECTIVE This study was designed to assess the diagnostic accuracy of standard nonsecretin-enhanced preprocedural magnetic resonance imaging/cholangiopancreatography (MRI/MRCP) in patients with and without pancreas divisum. METHODS Patients undergoing MRI/MRCP followed by endoscopic retrograde cholangiopancreatography with between 2009 and 2016 were reviewed. The diagnostic accuracy of the MRI/MRCP was evaluated against the pancreatography. A subsequent independent blinded re-review performed by an expert abdominal radiologist was also evaluated. Multivariate binary logistic regression was performed to assess the impact of clinicopathologic factors on the diagnostic accuracy. RESULTS A total of 189 patients were included in analysis. The sensitivity, specificity, positive predictive value, and negative predictive value of MRI/MRCP for pancreas divisum were 63%, 97%, 94%, and 82% initially and 81%, 91%, 91%, and 82% on the expert review. Motion artifact, the presence of pancreatic tumor, and pancreatic necrosis were not found to significantly impact the accuracy. A normal diameter pancreatic duct (P = 0.04) and complete divisum anatomy were correlated with improved accuracy (P = 0.001). CONCLUSIONS Although expert review, normal duct diameter, and complete divisum are associated with increased sensitivity, pancreas divisum may be uncharacterized by preprocedural MRI in 19% to 37% of patients before the index endoscopic retrograde cholangiopancreatography.
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Wen J, Li T, Liu L, Bie LK, Gong B. Long-term outcomes of therapeutic ERCP in pediatric patients with pancreas divisum presenting with acute recurrent or chronic pancreatitis. Pancreatology 2019; 19:834-841. [PMID: 31421974 DOI: 10.1016/j.pan.2019.08.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 08/02/2019] [Accepted: 08/07/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the long-term outcomes of therapeutic endoscopic retrograde cholangiopancreatography (ERCP) for pediatric patients with pancreas divisum (PD) presenting with acute recurrent pancreatitis (ARP) or chronic pancreatitis (CP). METHODS Between May 2008 and August 2017, pediatric patients with PD who received endotherapy at Ruijin Hospital were identified and grouped according to clinical presentation, namely ARP and CP. Primary success was defined as patients' improvement in symptoms after index ERCPs, without further intervention or any analgesic. RESULTS A total of 74 ERCPs were performed in 38 pediatric patients. The frequency of at least 1 genetic mutation identified in patients with ARP and CP was 44.4% and 68.4%, respectively. Patients with CP required more ERCPs than those with ARP (2.4 ± 1.7 vs. 1.1 ± 0.4, P = 0.005). The incidence of post-ERCP complications was 14.9%, including pancreatitis of 13.5% and hemorrhage of 1.4%. During a median follow-up duration of 41 months (range, 12-123 months), the frequency of pancreatitis episodes decreased significantly from 2.31 to 0.45 (P < 0.0001). The 25% recurrence and reintervention rates were estimated at 25 and 48 months, respectively, without significant difference between patients with ARP or CP. There was a nonsignificant trend towards a higher rate of primary success in patients with ARP than those with CP (92.9% vs. 69.6%, P = 0.123). After further endotherapy, 91.3% patients with CP improved clinically. CONCLUSIONS Therapeutic ERCP is an effective and safe intervention for pediatric patients with symptomatic PD. Patients presenting with CP seem to achieve improvement after additional ERCPs.
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Affiliation(s)
- Jun Wen
- Digestive Endoscopy Center, Department of Gastroenterology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Tao Li
- Department of Gastroenterology, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Lei Liu
- Digestive Endoscopy Center, Department of Gastroenterology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Li-Ke Bie
- Digestive Endoscopy Center, Department of Gastroenterology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Biao Gong
- Digestive Endoscopy Center, Department of Gastroenterology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.
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Ferri V, Vicente E, Quijano Y, Ielpo B, Duran H, Diaz E, Fabra I, Caruso R. Diagnosis and treatment of pancreas divisum: A literature review. Hepatobiliary Pancreat Dis Int 2019; 18:332-336. [PMID: 31155429 DOI: 10.1016/j.hbpd.2019.05.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 05/13/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Pancreas divisum is a congenital embryological disease caused by a lack of fusion between the ventral and dorsal pancreatic ducts in the early stages of embryogenesis. Recurrent acute pancreatitis, chronic pancreatitis or chronic abdominal pain are the main clinical syndromes at presentation and occur in only 5% of the patients with pancreas divisum. This review aimed to discuss diagnosis and treatment strategies in patients with symptomatic pancreas divisum. DATA SOURCES We report a literature review from 1990 up to January 2018 to explore the various diagnostic modalities and surgical techniques and results reported in the surgical treatment of pancreas divisum. RESULTS There are limited reports available on this topic in the literature. We analyzed and described the main indications in the treatment of pancreas divisum, focusing on surgical treatment and a discussion of the different approaches. Furthermore, we report the results from our experience in two cases of pancreas divisum treated by pancreatic head resection with segmental duodenectomy (the Nakao procedure). CONCLUSIONS Pancreas divisum is a common pancreatic malformation in which only a few patients develop a symptomatic disease. Surgical treatment is needed in case of endoscopic drainage failure and in cases complicated with chronic pancreatitis and local complications. Many techniques, of greater or lesser complexity, have been proposed.
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Affiliation(s)
- Valentina Ferri
- Division of General Surgery, Sanchinarro Hospital, San Pablo University, calle oña 10, 28050 Madrid, Spain.
| | - Emilio Vicente
- Division of General Surgery, Sanchinarro Hospital, San Pablo University, calle oña 10, 28050 Madrid, Spain
| | - Yolanda Quijano
- Division of General Surgery, Sanchinarro Hospital, San Pablo University, calle oña 10, 28050 Madrid, Spain
| | - Benedetto Ielpo
- Division of General Surgery, Sanchinarro Hospital, San Pablo University, calle oña 10, 28050 Madrid, Spain
| | - Hipolito Duran
- Division of General Surgery, Sanchinarro Hospital, San Pablo University, calle oña 10, 28050 Madrid, Spain
| | - Eduardo Diaz
- Division of General Surgery, Sanchinarro Hospital, San Pablo University, calle oña 10, 28050 Madrid, Spain
| | - Isabel Fabra
- Division of General Surgery, Sanchinarro Hospital, San Pablo University, calle oña 10, 28050 Madrid, Spain
| | - Riccardo Caruso
- Division of General Surgery, Sanchinarro Hospital, San Pablo University, calle oña 10, 28050 Madrid, Spain
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Gonoi W, Hayashi TY, Hayashi N, Abe O. Association between chronic asymptomatic pancreatic hyperenzymemia and pancreatic ductal anomalies: a magnetic resonance cholangiopancreatography study. Abdom Radiol (NY) 2019; 44:2494-2500. [PMID: 30944960 DOI: 10.1007/s00261-019-02004-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE Elucidating the association between pancreatic ductal anomalies and chronic asymptomatic pancreatic hyperenzymemia using magnetic resonance cholangiopancreatography. METHODS We conducted a single-center, retrospective, case-control study. The healthy community group comprised 554 subjects who participated in a paid, whole-body health checkup program. The patient group comprised 14 subjects with idiopathic pancreatic hyperamylasemia or hyperlipasemia. All subjects underwent magnetic resonance cholangiopancreatography. The clinical features and incidence rates of pancreatic ductal anomalies were then compared between the groups. RESULTS Compared to the healthy community group, the patient group was significantly more likely to be ≥ age 65 (71.4% of patient group vs. 22.1% of healthy community group), have a history of diabetes mellitus (21.4% vs. 5.4%) or hypertension (35.7% vs. 11.4%), and to have pancreas divisum (21.4% vs. 2.7%), meandering main pancreatic duct (21.4% vs. 4.1%), Wirsungocele (14.3% vs. 1.1%), or dilated main pancreatic duct (14.3% vs. 2.3%). Multivariate analysis found that age ≥ 65 (odds ratio 8.76), presence of pancreas divisum (odds ratio 13.2), meandering main pancreatic duct (odds ratio 8.95), and Wirsungocele (odds ratio 17.6) were independent factors significantly associated with chronic asymptomatic pancreatic hyperenzymemia. CONCLUSIONS Pancreas divisum, meandering main pancreatic duct, and Wirsungocele were independently associated with chronic asymptomatic pancreatic hyperenzymemia.
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Affiliation(s)
- Wataru Gonoi
- Radiology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Takana Yamakawa Hayashi
- Radiology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Naoto Hayashi
- Computational Diagnostic Radiology and Preventive Medicine, The University of Tokyo, Tokyo, Japan
| | - Osamu Abe
- Radiology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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Abstract
INTRODUCTION The significance of pancreas divisum (PD) as a risk factor for pancreatitis is controversial. We analyzed the characteristics of children with PD associated with acute recurrent or chronic pancreatitis to better understand its impact. PATIENTS AND METHODS We compared children with or without PD in the well-phenotyped INSPPIRE (INternational Study group of Pediatric Pancreatitis: In search for a cuRE) cohort. Differences were analyzed using 2-sample t test or Wilcoxon rank sum test for continuous variables, Pearson χ or Fisher exact test for categorical variables. RESULTS PD was found in 52 of 359 (14.5%) subjects, a higher prevalence than the general population (∼7%). Females more commonly had PD (71% vs. 55%; P=0.02). Children with PD did not have a higher incidence of mutations in SPINK1, CFTR, CTRC compared with children with no PD. Children with PD were less likely to have PRSS1 mutations (10% vs. 34%; P<0.01) or a family history of pancreatitis (P<0.05), and more likely to have hypertriglyceridemia (11% vs. 3%; P=0.03). Children with PD underwent significantly more endoscopic procedures and pancreatic sphincterotomy. Patients with PD had fewer attacks of acute pancreatitis (P=0.03) and were less likely to develop exocrine pancreatic insufficiency (P=0.01). Therapeutic endoscopic retrograde cholangiopancreatography was considered most helpful if pancreatic duct was impacted with stones (83% helpful). CONCLUSIONS PD is likely a risk factor for acute recurrent pancreatitis and chronic pancreatitis in children that appears to act independently of genetic risk factors. Patients with PD and stones obstructing the pancreatic duct benefit most from therapeutic endoscopic retrograde cholangiopancreatography.
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Jalal M, Campbell JA, Hopper AD. Practical guide to the management of chronic pancreatitis. Frontline Gastroenterol 2019; 10:253-260. [PMID: 31288255 PMCID: PMC6583580 DOI: 10.1136/flgastro-2018-101071] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 08/19/2018] [Indexed: 02/04/2023] Open
Abstract
Chronic pancreatitis (CP) is an irreversible fibroinflammatory disorder of the pancreas. It presents with relapsing, remitting upper abdominal pain accompanied by features of malabsorption due to pancreatic exocrine insufficiency and endocrine deficiency with the development of diabetes mellitus. The associated increased hospitalisation and high economic burden are related to CP often presenting at advanced stage with irreversible consequences. Diagnosing CP at an early stage is still challenging and therefore CP is believed to be under-reported. Our understanding of this disease has evolved over the last few years with attempts to redesign the definition of CP. Better recognition of the risk factors and conditions associated with CP can lead to an earlier diagnosis and coupled with a multidisciplinary approach to treatment, ultimately reduce complications. This article reviews the epidemiology, risk factors, diagnosis and management of CP.
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Affiliation(s)
- Mustafa Jalal
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | | | - Andrew D Hopper
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
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Treatment of Difficult Minor Papilla Cannulation in Patients of Pancreatic Divisum: Using Endoscopic Ultrasonography-guided Puncture Combined With Endoscopic Retrograde Cholangiopancreatography: 2 Cases and Literature Review. Surg Laparosc Endosc Percutan Tech 2019; 29:e60-e64. [PMID: 31166291 DOI: 10.1097/sle.0000000000000686] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
CONTEXT Pancreas divisum (PD), the most common congenital anatomic variation of the pancreatic ductal system, is still rare in clinical practice. Endoscopic retrograde cholangiopancreatography (ERCP) is the first-line treatment for patients with symptomatic PD. However, even by experienced endoscopists, the procedure of ERCP can fail in 3% to 10% of cases. Traditionally, if we fail in cannulation we have no choice but to rely on surgery. CASE REPORT The 2 case reports of PD in this study with cannulation were both unsuccessful, fortunately, the use of endoscopic ultrasonography-guided pancreatic duct puncture combined with ERCP was eventually successful in treatment. CONCLUSIONS Using endoscopic ultrasonography-guided pancreatic duct puncture combined with ERCP is safe and effective for the treatment of the patients of difficult minor papilla cannulation in patients of PD, and can be used as a remedy for minor papilla cannulation failure.
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Covantev S. Pancreas divisum: a reemerging risk factor for pancreatic diseases. ROMANIAN JOURNAL OF INTERNAL MEDICINE = REVUE ROUMAINE DE MEDECINE INTERNE 2018; 56:233-242. [PMID: 30521477 DOI: 10.2478/rjim-2018-0022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Indexed: 12/30/2022]
Abstract
Pancreas divisum (PD) is the most common developmental anatomic variant of pancreatic duct. The attention towards the PD has grown significantly since there are reports that this condition may cause acute relapsing pancreatitis, chronic pancreatitis and chronic abdominal pain syndrome. Furthermore, over the years, there have been multiple reports of PD associated with different types of tumors. There is evidence that PD can be associated with pancreatic tumors (up to 12.5% of cases). The golden standard for diagnosing PD is endoscopic retrograde cholangiopancreatography, but since it is an invasive procedure magnetic resonance cholangiopancreatography with secretin is a good alternative. In case the patient is symptomatic, endoscopic or surgical treatment should be performed. This review describes the key points of the pathophysiology, diagnostic modalities, risks of pancreatitis and tumors, as well as treatment options of PD.
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Affiliation(s)
- Serghei Covantev
- Laboratory of Allergology and Clinical Immunology, "Nicolae Testemitanu" State University of Medicine and Pharmacy, Chisinau, Republic of Moldova
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Abstract
Recurrent acute pancreatitis (RAP) is a clinically significant problem globally. The etiology remains unclear in approximately 10% to 15% of patients despite a thorough workup. Data on natural history and efficacy of treatments are limited. We aimed to establish criteria for diagnosis, evaluate the causative factors, and arrive at a consensus on the appropriate workup and management of patients with RAP. The organizing committee was formed, and a set of questions was developed based on the current evidence, controversies, and topics that needed further research. After a vetting process, these topics were assigned to a group of experts from around the world with special interest in RAP. Data were presented as part of a workshop on RAP organized as a part of the annual meeting of the America Pancreatic Association. Pretest and Posttest questions were administered, and the responses were tabulated by the current Grades of Recommendation Assessment, Development and Evaluation system. The consensus guidelines were established in the format of a diagnostic algorithm. Several deficiencies were identified with respect to data on etiology, treatment efficacies, and areas that need immediate research.
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Lu Y, Xu B, Chen L, Bie LK, Gong B. Endoscopic Intervention through Endoscopic Retrograde Cholangiopancreatography in the Management of Symptomatic Pancreas Divisum: A Long-Term Follow-Up Study. Gut Liver 2017; 10:476-82. [PMID: 26787401 PMCID: PMC4849703 DOI: 10.5009/gnl15362] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background/Aims To evaluate the efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) for the treatment of symptomatic pancreas divisum (PD) and to discuss whether ERCP procedures and outcomes in younger patients differ from those of adults. Methods Symptomatic patients with PD were included in the study and divided into underaged (age ≤17 years) and adult (age ≥18 years) group. The clinical information of each patient was reviewed, and then the patients were contacted by telephone or their medical records were reviewed to determine their long-term follow-up outcomes. Results A total of 141 procedures were performed in 82 patients (17 underaged and 65 adult patients). The ERCP indications included abdominal pain (39.02%), pancreatitis (12.20%), recurrent pancreatitis (36.59%), and other discomfort (12.20%). The endoscopic interventions included endoscopic pancreatic sphincterotomy in 44.68% of the patients, bouginage in 26.95%, pancreatic ductal stone extraction in 19.15%, endoscopic nasopancreatic drainage in 21.99%, and endoscopic retrograde pancreatic drainage in 56.74%. After a median follow-up of 41 months, the overall response rate was 62.32%. Between the underaged group and the adult group, significant differences were not observed in the ERCP procedures, complications and long-term follow-up results. Conclusions ERCP is a safe and effective treatment for symptomatic PD. Based on the details, complications, and follow-up results, the ERCP procedure did not present differences between the underaged and adult groups.
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Affiliation(s)
- Yi Lu
- Digestive Endoscopy Center, Department of Gastroenterology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Bin Xu
- Digestive Endoscopy Center, Department of Gastroenterology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Lu Chen
- Digestive Endoscopy Center, Department of Gastroenterology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Li-Ke Bie
- Digestive Endoscopy Center, Department of Gastroenterology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Biao Gong
- Digestive Endoscopy Center, Department of Gastroenterology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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Balloon Dilatation of the Minor Duodenal Papilla Up to 4 mm is Safe in a Porcine Model. Surg Laparosc Endosc Percutan Tech 2017; 27:e44-e47. [PMID: 28520650 DOI: 10.1097/sle.0000000000000414] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Balloon dilatation of the minor duodenal papilla is a treatment option for symptomatic pancreas divisum. The histologic effects of balloon dilatation have not yet been evaluated. The aim of this study is to investigate the tolerated extent of dilatation of the minor papilla. MATERIALS AND METHODS A dilatation of the minor papilla was performed in freshly explanted pancreas of pigs using biliary balloon dilatators. Three organs were not dilated (control group), in each 8 organs a dilatation of 4, 6, and 8 mm, respectively, was performed. Tissue damage was assessed by microscopic evaluation. Ductal wall disruption and perforation as well as a semiquantitative inflammation score was described and compared. RESULTS Ductal wall disruption was increased by dilatation of 6 (5/8; P=0.019) and 8 mm (6/8; P=0.006) compared with 4 mm (1/8). Median inflammation score was 0 (0 to 0), 1 (0 to 2), and 1 (0 to 2) for dilatation of 4, 6, and 8 mm, respectively (4 vs. 6 mm, P=0.007; 4 vs. 8 mm, P=0.026). No perforation occurred in the 4 (0/8) and 6 mm (0/8) group, 1 perforation occurred in the 8 mm group (1/8). CONCLUSIONS A dilatation of up to 4 mm seems to be safe. However, dilatation of the minor papilla from 4 mm onwards is increasingly associated with tissue damage. These findings should be considered in endoscopic procedures dilating the minor duodenal papilla.
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Michailidis L, Aslam B, Grigorian A, Mardini H. The efficacy of endoscopic therapy for pancreas divisum: a meta-analysis. Ann Gastroenterol 2017; 30:550-558. [PMID: 28845111 PMCID: PMC5566776 DOI: 10.20524/aog.2017.0159] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 04/24/2017] [Indexed: 12/16/2022] Open
Abstract
Background The purpose of this study was to perform a meta-analysis assessing the efficacy and predictors of success of endoscopic therapy in the management of patients with pancreas divisum. Methods An electronic database search (PubMed and ScienceDirect) was performed for relevant studies. Studies were selected based on predefined criteria and data were extracted on patient population, follow up, endotherapy methods, success rates and complication rates. A random-effect model was used to pool the effect size across studies. Heterogeneity testing and publication bias assessment were performed. Multivariate regression analysis was performed to identify predictors of successful endoscopic therapy. Results Of 381 articles reviewed, 23 studies with 874 patients met the inclusion criteria. All were case series with suboptimal quality. Endoscopic therapy included minor papilla sphincterotomy, minor papilla sphincteroplasty and dorsal duct stenting. Mean follow-up duration was 37 months. The rate of “improvement” as defined by authors after endoscopic therapy varied significantly across studies, ranging from 31-96%: 589/874 patients were reported to have improved, corresponding to a pooled efficacy rate of 67.5% (95% confidence interval [CI] 0.610-0.734; P=0.0001). The pooled rate of pancreatitis after endoscopic retrograde cholangiopancreatography was 10.1% (95%CI 0.084-0.124; 2-sided P=0.0001). On subgroup analysis, patients with recurrent acute pancreatitis had better endoscopic outcomes (pooled efficacy rate 76%, 95%CI 0.712-0.803, P=0.0001). Dorsal duct stenting and longer follow up were the only parameters predictive of successful endotherapy. Significant heterogeneity was observed within and across studies. Conclusions Endoscopic efficacy in pancreas divisum is estimated at 67.5%. Available studies are of poor quality with significant heterogeneity. Comparative studies with rigorous methodology are needed.
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Affiliation(s)
- Lamprinos Michailidis
- Department of Medicine, Division of Digestive Diseases and Nutrition, University of Kentucky College of Medicine, USA
| | - Bilal Aslam
- Department of Medicine, Division of Digestive Diseases and Nutrition, University of Kentucky College of Medicine, USA
| | - Alla Grigorian
- Department of Medicine, Division of Digestive Diseases and Nutrition, University of Kentucky College of Medicine, USA
| | - Houssam Mardini
- Department of Medicine, Division of Digestive Diseases and Nutrition, University of Kentucky College of Medicine, USA
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A systematic review and quantitative analysis of different therapies for pancreas divisum. Am J Surg 2017; 214:525-537. [PMID: 28110914 DOI: 10.1016/j.amjsurg.2016.12.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Accepted: 12/26/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Pancreas divisum is the most common anatomical variation of pancreatic ductal system affecting 5-10% of population. Therapy includes different endoscopic and surgical procedures. The aim of this article was to summarize actual evidence of different treatment. METHODS A Medline search was performed to identify all studies, investigating endoscopic or surgical therapy of Pancreas divisum. An individual data simulation model was applied to compare endoscopic and surgical studies. RESULT 56 observational studies (31 endoscopic and 25 surgical studies) were included in analyses. Surgery was significantly superior to endoscopic treatment in terms of success rate (72% vs. 62.3), complication rate (23.8% vs. 31.3%) and re-intervention rate (14.4% vs. 28.3%). CONCLUSION Surgery may be superior to endoscopy in terms of treatment success and complications. There is no study comparing these two therapies. Consequently, a randomized trial is needed to clarify if endoscopy or surgery is superior in the therapy of pancreas divisum.
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Izzo P, Di Cello P, Pugliese F, Izzo S, Grande R, Biancucci F, Sinaimeri G, Razionale F, Costi U, Al Mansour M, Muneer A, Valabrega S, Izzo L. Pancreas divisum: correlation between anatomical abnormalities and bile precipitation in the gallbladder in seven patients. G Chir 2016; 37:155-157. [PMID: 27938531 DOI: 10.11138/gchir/2016.37.4.155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Pancreas divisum is a genetic defect associated with recurrent acute pancreatitis due to insufficient drainage of the accessory pancreatic duct. Seven young patients diagnosed with pancreatic divisum and thickening of the gallbladder bile as shown on magnetic resonance cholangio-pancreatography without pancreatic ductal changes underwent laparoscopic cholecystectomy. During the mean follow-up of 32 months no episode of pancreatitis was reported. There is an association between PD and higher concentration of bile in the gallbladder. Cholecystectomy can be considered curative in patients with PD in the absence of indications for major surgery.
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The Value of Secretin-Enhanced MRCP in Patients With Recurrent Acute Pancreatitis. AJR Am J Roentgenol 2016; 208:315-321. [PMID: 27824485 DOI: 10.2214/ajr.16.16566] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The purpose of this study is to assess the additional value of secretin-enhanced MRCP over conventional (non-secretin-enhanced) MRCP in diagnosing disease in patients with recurrent acute pancreatitis. MATERIALS AND METHODS A retrospective review of a radiology database found 72 patients with recurrent acute pancreatitis who had secretin-enhanced MRCP and ERCP correlation within 3 months of each other between January 2007 and December 2011. Of these patients, 54 had no history of pancreatic tumor or surgery and underwent MRI more than 3 months after an episode of acute pancreatitis. In addition, 57 age- and sex-matched control subjects with secretin-enhanced MRCP and ERCP correlation and without a diagnosis of recurrent acute pancreatitis or chronic pancreatitis were enrolled as the control group. All studies were anonymized, and secretin-enhanced MRCP images (image set A) were separated from conventional 2D and 3D MRCP and T2-weighted images (image set B). Image sets A and B for each patient were assigned different and randomized case numbers. Two blinded reviewers independently assessed both image sets for ductal abnormalities and group A image sets for exocrine response to secretin. RESULTS There were statistically significantly more patients with recurrent acute pancreatitis with reduced exocrine function compared with patients in the control group (32% vs 9%; p < 0.01) on secretin-enhanced images. Patients with recurrent acute pancreatitis were more likely to have side branch dilation (p = 0.02; odds ratio, 3.6), but not divisum, compared with the control group. Secretin-enhanced images were superior to non-secretin-enhanced images for detecting ductal abnormalities in patients with recurrent acute pancreatitis, with higher sensitivity (76% vs 56%; p = 0.01) and AUC values (0.983 vs 0.760; p < 0.01). CONCLUSION Up to one-third of patients with recurrent acute pancreatitis showed exocrine functional abnormalities. Secretin-enhanced MRCP had a significantly higher yield for ductal abnormalities than did conventional MRI and should be part of the MRCP protocol for investigation of patients with recurrent acute pancreatitis.
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Otsuka S, Sugiura T, Uesaka K. Acute obstructive pancreatitis after pancreas-sparing total duodenectomy in a patient with pancreas divisum: a case report. Surg Case Rep 2016; 2:126. [PMID: 27817166 PMCID: PMC5097779 DOI: 10.1186/s40792-016-0255-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 11/02/2016] [Indexed: 11/23/2022] Open
Abstract
Background Pancreas-sparing total duodenectomy (PSTD) is an ideal recommended procedure for patients with multiple duodenal adenomas or early duodenal cancer. We herein report a rare but serious complication of PSTD. Case presentation A 20-year-old woman with duodenal adenocarcinoma underwent PSTD. On postoperative day one, she complained of severe abdominal pains. Her serum amylase and serum pancreatic amylase levels were extremely elevated (Amy, 1296 IU/L; P-Amy, 1273 IU/L). With contrast enhanced CT, acute obstructive pancreatitis with pancreas divisum due to the ligation of the dorsal pancreatic duct was highly suspected. An emergency operation was performed to relieve the pancreatic duct obstruction, and an additional anastomosis between the dorsal pancreatic duct and jejunum was performed. The patient’s postoperative course was mostly uneventful, and her discomfort improved immediately. Conclusion When we perform pancreas-sparing total duodenectomy, some form of pancreatography is necessary to exclude pancreas divisum.
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Affiliation(s)
- Shimpei Otsuka
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007 Shimo-Nagakubo, Sunto-Nagaizumi, Shizuoka, 411-8777, Japan
| | - Teiichi Sugiura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007 Shimo-Nagakubo, Sunto-Nagaizumi, Shizuoka, 411-8777, Japan.
| | - Katsuhiko Uesaka
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007 Shimo-Nagakubo, Sunto-Nagaizumi, Shizuoka, 411-8777, Japan
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Somani P, Navaneethan U. Role of ERCP in Patients With Idiopathic Recurrent Acute Pancreatitis. ACTA ACUST UNITED AC 2016; 14:327-39. [PMID: 27371265 DOI: 10.1007/s11938-016-0096-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OPINION STATEMENT Recurrent acute pancreatitis (RAP) is defined based on the occurrence of two or more episodes of acute pancreatitis. RAP is differentiated from chronic pancreatitis based on the presence of a normal morphological appearance of the pancreas between episodes. RAP can be due to a variety of etiologies including common bile duct stones or sludge, sphincter of Oddi dysfunction (SOD), pancreas divisum (PD), anomalous pancreaticobiliary junction, genetic mutations, and alcohol related. In approximately 30 % of patients, the etiology of RAP is unclear and the term "idiopathic" is used. Endoscopic retrograde cholangiopancreatography (ERCP) can be utilized in both the diagnosis and the initial management of RAP, but it has known limitations and risks. Since gallbladder sludge and SOD account for most cases with RAP, cholecystectomy and, eventually, endoscopic biliary and/or pancreatic sphincterotomy are performed as a part of management. In patients with PD-associated RAP, data from uncontrolled and primarily retrospective studies point toward a benefit from minor papillary endoscopic intervention. However, given the lack of quality data from prospective randomized controlled trials (RCTs), endoscopic management in such patients remains an individualized decision, and RCTs are needed to ascertain its true long-term benefit. Future studies to investigate the role of endoscopic therapy in preventing progression to chronic pancreatitis are needed.
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Affiliation(s)
- Piyush Somani
- Center for Interventional Endoscopy, University of Central Florida College of Medicine, Florida Hospital, 601 E Rollins Street, Orlando, FL, 32803, USA
| | - Udayakumar Navaneethan
- Center for Interventional Endoscopy, University of Central Florida College of Medicine, Florida Hospital, 601 E Rollins Street, Orlando, FL, 32803, USA.
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Das R, Yadav D, Papachristou GI. Endoscopic Treatment of Recurrent Acute Pancreatitis and Smoldering Acute Pancreatitis. Gastrointest Endosc Clin N Am 2015; 25:737-48. [PMID: 26431601 DOI: 10.1016/j.giec.2015.06.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Recurrent acute pancreatitis (RAP) is a challenging condition that can lead to chronic pancreatitis and long-term morbidity. Etiology-based treatment can potentially have an impact on the natural history of RAP and its progression to chronic pancreatitis. In cases of divisum-associated RAP and idiopathic RAP, several studies have been performed to evaluate the efficacy of endoscopic therapy in alleviation of symptoms and frequency of AP events. This review discusses the literature available on these topic as well as touching on the role of endoscopic therapy in smoldering acute pancreatitis.
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Affiliation(s)
- Rohit Das
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, PUH, M2, C Wing, 200 Lothrop Street, Pittsburgh, PA 15213, USA
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, PUH, M2, C Wing, 200 Lothrop Street, Pittsburgh, PA 15213, USA
| | - Georgios I Papachristou
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, PUH, M2, C Wing, 200 Lothrop Street, Pittsburgh, PA 15213, USA.
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Bor R, Madácsy L, Fábián A, Szepes A, Szepes Z. Endoscopic retrograde pancreatography: When should we do it? World J Gastrointest Endosc 2015; 7:1023-1031. [PMID: 26322155 PMCID: PMC4549659 DOI: 10.4253/wjge.v7.i11.1023] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Revised: 06/30/2015] [Accepted: 08/14/2015] [Indexed: 02/05/2023] Open
Abstract
Endoscopic retrograde pancreatography (ERP) is an accurate imaging modality in the diagnosis of pancreatobiliary diseases. However, its use has been substantially reduced due to the invasiveness of procedure, the risk of complications and the widespread availability of non-invasive cross-section imaging techniques (computed tomography, magnetic resonance imaging, and endoscopic ultrasound). Since the introduction of endoscopic sphincterotomy, ERP has transformed from diagnostic method to an almost exclusively therapeutic procedure. Pancreatic duct injection substantially increased the risk of post-ERP pancreatitis (1.6%-15.7%); therefore, according to international guidelines ERP is recommended only in cases where biliary intervention is required. However, the role of ERP in the management of pancreatic diseases is currently not clearly defined, but in some cases the filling of pancreatic duct may provide essential information complementing the results of non-invasive imaging techniques. The aim of this publication is to systematically summarize the literature dealing with the diagnostic yield of ERP. We would like to define the precise indications of ERP and overview a diagnostic protocol of pancreatic diseases depending on international guidelines and the opinion of Hungarian experts, because it may improve the diagnostic accuracy, minimize of burden of patients and reduce the risk of procedure related complications.
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Nishi T, Kawabata Y, Ishikawa N, Araki A, Yano S, Maruyama R, Tajima Y. Intraductal papillary mucinous carcinoma of the pancreas associated with pancreas divisum: a case report and review of the literature. BMC Gastroenterol 2015; 15:78. [PMID: 26152300 PMCID: PMC4495851 DOI: 10.1186/s12876-015-0313-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 06/30/2015] [Indexed: 01/15/2023] Open
Abstract
Background Pancreas divisum, the most common congenital anomaly of the pancreas, is caused by failure of the fusion of the ventral and dorsal pancreatic duct systems during embryological development. Although various pancreatic tumors can occur in patients with pancreas divisum, intraductal papillary mucinous neoplasm is rare. Case presentation A 77-year-old woman was referred to our hospital because she was incidentally found to have a cystic tumor in her pancreas at a regular health checkup. Contrast-enhanced abdominal computed tomography images demonstrated a cystic tumor in the head of the pancreas measuring 40 mm in diameter with slightly enhancing mural nodules within the cyst. Endoscopic retrograde pancreatography via the major duodenal papilla revealed a cystic tumor and a slightly dilated main pancreatic duct with an abrupt interruption at the head of the pancreas. The orifice of the major duodenal papilla was remarkably dilated and filled with an abundant extrusion of mucin, and the diagnosis based on pancreatic juice cytology was “highly suspicious for adenocarcinoma”. Magnetic resonance cholangiopancreatography depicted a normal, non-dilated dorsal pancreatic duct throughout the pancreas. The patient underwent a pylorus-preserving pancreaticoduodenectomy under the diagnosis of intraductal papillary mucinous neoplasm with suspicion of malignancy arising in the ventral part of the pancreas divisum. A pancreatography via the major and minor duodenal papillae on the surgical specimen revealed that the ventral and dorsal pancreatic ducts were not connected, and the tumor originated in the ventral duct, i.e., the Wirsung’s duct. Microscopically, the tumor was diagnosed as intraductal papillary mucinous carcinoma with microinvasion. In addition, marked fibrosis with acinar cell depletion was evident in the ventral pancreas, whereas no fibrotic change was noted in the dorsal pancreas. Conclusion Invasive ductal carcinomas of the pancreas associated with pancreas divisum usually arise from the dorsal pancreas, in which the occurrence of pancreatic cancer may link to underlying longstanding chronic pancreatitis in the dorsal pancreas; however, the histopathogenesis of intraductal papillary mucinous neoplasm in this anomaly is a critical issue that warrants further investigation in future.
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Affiliation(s)
- Takeshi Nishi
- Deparment of Surgery, Matsue Red Cross Hospital, 200 Horo-machi, Matsue, Shimane, 690-8506, Japan. .,Department of Digestive and General Surgery, Shimane University Faculty of Medicine, 89-1 Enyacho, Izumo, Shimane, 693-8501, Japan.
| | - Yasunari Kawabata
- Department of Digestive and General Surgery, Shimane University Faculty of Medicine, 89-1 Enyacho, Izumo, Shimane, 693-8501, Japan.
| | - Noriyoshi Ishikawa
- Department of Organ Pathology, Shimane University Faculty of Medicine, 89-1 Enyacho, Izumo, Shimane, 693-8501, Japan.
| | - Asuka Araki
- Department of Organ Pathology, Shimane University Faculty of Medicine, 89-1 Enyacho, Izumo, Shimane, 693-8501, Japan.
| | - Seiji Yano
- Department of Digestive and General Surgery, Shimane University Faculty of Medicine, 89-1 Enyacho, Izumo, Shimane, 693-8501, Japan.
| | - Riruke Maruyama
- Department of Organ Pathology, Shimane University Faculty of Medicine, 89-1 Enyacho, Izumo, Shimane, 693-8501, Japan.
| | - Yoshitsugu Tajima
- Department of Digestive and General Surgery, Shimane University Faculty of Medicine, 89-1 Enyacho, Izumo, Shimane, 693-8501, Japan.
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Abstract
PURPOSE To assess the additional value of secretin-enhanced MRCP (SMRCP) over conventional MRCP in diagnosing divisum. METHODS Retrospective HIPAA-compliant and IRB-approved review found 140 patients with SMRCP and ERCP correlation within 6 months of each other. All studies were anonymized and the SMRCP images (SMRCP image set) were separated from 2D and 3D MRCP and axial and coronal T2-weighted images (conventional MRI image set). Each image set on each patient was assigned different and randomized case numbers. Two reviewers (R1 and R2) independently reviewed the image sets for divisum vs. no divisum, complete divisum vs. incomplete divisum, and the certainty of diagnosis (1 = definitely certain, 2 = moderately certain, and 3 = unsure). ERCP findings were taken as gold standard. RESULTS There was no difference in age and gender between the divisum (n = 97, with 13 incomplete divisum) and no divisum (n = 43) groups. In diagnosing divisum anatomy, the sensitivity was higher for SMRCP compared to conventional MRI for R1 (84.5 vs. 72.2, p = 0.02) but not R2 (89.7 vs. 84.4, p = 0.25). The specificity was higher in SMRCP image set compared to conventional MRI (R1: 88.1 vs. 76.2, p = 0.01; R2: 81.4 vs. 65.1, p < 0.001). The mean area under ROC curve was higher for SMRCP image set (R1: 0.86 vs. 0.74, p = 0.01; R2: 0.87 vs. 0.74, p = 0.01). The certainty of diagnosis was higher in SMRCP image set compared to conventional MRI (p = 0.02 for both reviewers). SMRCP was not found to be superior in distinguishing incomplete from complete divisum. The main reasons for erroneous SMRCP diagnosis were the presence of an ansa loop in the main duct and ductal strictures due to chronic pancreatitis. CONCLUSION Even though the reviewers had more sequences (axial and coronal) to evaluate in the non-secretin image set, there was some improvement in diagnosing divisum with SMRCP.
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Boninsegna E, Manfredi R, Ventriglia A, Negrelli R, Pedrinolla B, Mehrabi S, Gabbrielli A, Pozzi Mucelli R. Santorinicele: secretin-enhanced magnetic resonance cholangiopancreatography findings before and after minor papilla sphincterotomy. Eur Radiol 2015; 25:2437-44. [DOI: 10.1007/s00330-015-3644-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 11/27/2014] [Accepted: 01/30/2015] [Indexed: 01/31/2023]
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Mariani A, Di Leo M, Petrone MC, Arcidiacono PG, Giussani A, Zuppardo RA, Cavestro GM, Testoni PA. Outcome of endotherapy for pancreas divisum in patients with acute recurrent pancreatitis. World J Gastroenterol 2014; 20:17468-17475. [PMID: 25516660 PMCID: PMC4265607 DOI: 10.3748/wjg.v20.i46.17468] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 05/09/2014] [Accepted: 07/24/2014] [Indexed: 02/06/2023] Open
Abstract
AIM To assess the rate of relapses of acute pancreatitis (AP), recurrent AP (RAP) and the evolution of endosonographic signs of chronic pancreatitis (CP) in patients with pancreas divisum (PDiv) and RAP. METHODS Over a five-year period, patients with PDiv and RAP prospectively enrolled were divided into two groups: (1) those with relapses of AP in the year before enrollment were assigned to have endoscopic therapy (recent RAP group); and (2) those free of recurrences were conservatively managed, unless they relapsed during follow-up (previous RAP group). All patients in both groups entered a follow-up protocol that included clinical and biochemical evaluation, pancreatic endoscopic ultrasonography (EUS) every year and after every recurrence of AP, at the same time as endoscopic retrograde cholangiopancreatography (ERCP). RESULTS Twenty-two were treated by ERCP and 14 were conservatively managed during a mean follow-up of 4.5 ± 1.2 years. In the recent RAP group in whom dorsal duct drainage was achieved, AP still recurred in 11 (57.9%) after the first ERCP, in 6 after the second ERCP (31.6%) and in 5 after the third ERCP (26.3%). Overall, endotherapy was successful 73.7%. There were no cases of recurrences in the previous RAP group. EUS signs of CP developed in 57.9% of treated and 64.3% of untreated patients. EUS signs of CP occurred in 42.8% of patients whose ERCPs were successful and in all those in whom it was unsuccessful (P = 0.04). There were no significant differences in the rate of AP recurrences after endotherapy and in the prevalence of EUS signs suggesting CP when comparing patients with dilated and non-dilated dorsal pancreatic ducts within each group. CONCLUSION Patients with PDiv and recent episodes of AP can benefit from endoscopic therapy. Effective endotherapy may reduce the risk of developing EUS signs of CP at a rate similar to that seen in patients of previous RAP group, managed conservatively. However, in a subset of patients, endotherapy, although successful, did not prevent the evolution of endosonographic signs of CP.
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Testoni PA. Acute recurrent pancreatitis: Etiopathogenesis, diagnosis and treatment. World J Gastroenterol 2014; 20:16891-16901. [PMID: 25493002 PMCID: PMC4258558 DOI: 10.3748/wjg.v20.i45.16891] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Revised: 06/19/2014] [Accepted: 09/19/2014] [Indexed: 02/06/2023] Open
Abstract
Acute recurrent pancreatitis (ARP) refers to a clinical entity characterized by episodes of acute pancreatitis which occurs on more than one occasion. Recurrence of pancreatitis generally occurs in a setting of normal morpho-functional gland, however, an established chronic disease may be found either on the occasion of the first episode of pancreatitis or during the follow-up. The aetiology of ARP can be identified in the majority of patients. Most common causes include common bile duct stones or sludge and bile crystals; sphincter of oddi dysfunction; anatomical ductal variants interfering with pancreatic juice outflow; obstruction of the main pancreatic duct or pancreatico-biliary junction; genetic mutations; alcohol consumption. However, despite diagnostic technologies, the aetiology of ARP still remains unknown in up to 30% of cases: in these cases the term “idiopathic” is used. Because occult bile stone disease and sphincter of oddi dysfunction account for the majority of cases, cholecystectomy, and eventually the endoscopic biliary and/or pancreatic sphincterotomy are curative in most of cases. Endoscopic biliary sphincterotomy appeared to be a curative procedure per se in about 80% of patients. Ursodeoxycholic acid oral treatment alone has also been reported effective for treatment of biliary sludge. In uncertain cases toxin botulin injection may help in identifying some sphincter of oddi dysfunction, but this treatment is not widely used. In the last twenty years, pancreatic endotherapy has been proven effective in cases of recurrent pancreatitis depending on pancreatic ductal obstruction, independently from the cause of obstruction, and has been widely used instead of more aggressive approaches.
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Magnetic resonance cholangiopancreatography in the diagnosis of pancreas divisum: a systematic review and meta-analysis. Pancreas 2014; 43:823-8. [PMID: 24743381 DOI: 10.1097/mpa.0000000000000143] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE This study aimed to perform a structured meta-analysis of all eligible studies to assess the overall diagnostic use of magnetic resonance cholangiopancreatography (MRCP) alone or with secretin enhancement (secretin-enhanced MRCP [S-MRCP]) in the detection of pancreas divisum. METHODS Two authors independently performed a comprehensive search of PubMed, MEDLINE, and the Cochrane Library from inception to September 2013. Studies were included if they allowed construction of 2 × 2 contingency tables of MRCP and/or S-MRCP compared with criterion standard. DerSimonian-Laird random effect models were used to estimate the pooled sensitivity, specificity, specificity, and quantitative receiver operating characteristics. RESULTS Of 51 citations, 10 studies with 1474 patients were included. Secretin-enhanced MRCP had a higher overall diagnostic performance than MRCP (S-MRCP: pooled sensitivity, 86% [95% confidence interval (CI), 77%-93%]; specificity, 97% [95% CI, 94%-99%]; and area under the curve, 0.93 ± 0.056 compared with MRCP: sensitivity, 52% [95% CI, 45%-59%]; specificity, 97% [95% CI, 94%-99%]; and area under the curve, 0.76 ± 0.104). Pooled diagnostic odds ratios were 72.19 (95% CI, 5.66-938.8) and 23.39 (95% CI, 7.93-69.02) for S-MRCP and MRCP, respectively. Visual inspection of the funnel plot showed low potential for publication bias. CONCLUSIONS Secretin-enhanced MRCP has a much higher diagnostic accuracy than MRCP and should be preferred for diagnosis of pancreas divisum.
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Abstract
OBJECTIVE A subpopulation of patients with pancreas divisum experience symptomatic events such as recurrent acute pancreatitis and chronic pancreatitis. Minor papilla sphincterotomy has been reported as being an effective treatment. The aim of this study was to evaluate the safety and efficacy of endoscopic balloon dilation for the minor papilla. METHODS Between 2000 and 2012, 16 patients were retrospectively included in this study. After endoscopic balloon dilation for the minor papilla was received, a pancreatic stent or a nasal pancreatic drainage catheter was placed for 1 week. If a stricture or obstruction was evident, it was treated with balloon dilation followed by long-term stent placement (1 year). When an outflow of pancreatic juice was disturbed by a pancreatic stone, endoscopic stone extraction was performed. RESULTS Balloon dilation and stent placement were achieved and were successful in all the cases (16/16; 100%). Clinical improvement was achieved in 7 (84.7%) of the 9 patients with recurrent acute pancreatitis and in 6 (85.7%) of the 7 patients with chronic pancreatitis. Early complications were observed in 1 (6.3%) patient. Pancreatitis or bleeding related to balloon dilation was not observed. CONCLUSIONS Endoscopic balloon dilation for the minor papilla is feasible for the management of symptomatic pancreas divisum.
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