Pancreatic ductal system obstruction and acute recurrent pancreatitis

Table 1 Potential causes of pancreatic ductal obstruction in acute recurrent pancreatitis

Potential causes	Diagnostic evaluation patient selection	Potential treatment strategies
Congenital variants
-PD ± Santorinicele	S-MRCP	ERCP ± EPS at the minor papilla
		± transient dorsal duct stenting
-APBU	S-MRCP	ES
-Choledochocele	S-MRCP	EBS
-TypeI& IV choledochal cyst	S-MRCP	Surgical resection + HJ
-Duodenal duplication cyst	S-MRCP	Endoscopic snare resection
		or surgical resection
-Annular pancreas	S-MRCP	ERCP + EPS
		or surgical gastrojejunostomy
Acquired obstructive conditions
-Suspected neoplasm
ampullary tumor	EUS, S-MRCP	Curative/palliative endotherapy
MPD stricture	EUS, S-MRCP	or
IPMT	EUS, S-MRCP	surgery
-Suspected early CP	EUS, S-MRCP	ERCP + EPS
		± transient MPD stenting
-Groove pancreatitis (CDDW)	EUS, S-MRCP	ERCP + dual ES + MPD stenting
		or surgery or somatostatin
-Pancreatic SOD typeI
Type II	S-MRCP	ERCP + dual ES + transient MPD stenting
Type III

PD: Pancreas divisum; APBU: Anomalous pancreaticobiliary union; MPD: Main pancreatic duct; IPMT: Intraductal papillary mucinous tumor; CP: Chronic pancreatitis; CDDW: Cystic dystrophy of the duodenal wall; SOD: Sphincter of Oddi dysfunction; S-MRCP: Secretin-enhanced magnetic resonance cholangiopancreatography; EUS: Endoscopic ultrasonography; ERCP: Endoscopic retrograde cholangiopancreatography; EPS: Endoscopic pancreatic sphincterotomy; ES: Endoscopic sphincterotomy; EBS: Endoscopic biliary sphincterotomy; HJ: Hepaticojejunostomy.