Journal of Medicine Vol 2 - Amrita Institute of Medical Sciences and ...

Amrita Journal of Medicine
REFERENCES
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Radiology Quiz (Answer)
DIAGNOSIS: Pancreas divisum
DISCUSSION:
MR cholangiopancreatography(MRCP) image shows the main pancreatic duct(PD) crossing the common bile duct(CBD)
and entering into minor papilla proximal to CBD insertion suggestive of Pancreas divisum. Minor duct joins with the
CBD.
Embryologically pancreas develops from two components namely the dorsal and ventral pancreas. When the rotation
of bowel occurs, the main pancreatic duct in the dorsal pancreas combines with the ventral component to form the main
duct of Wirsung, which enters through the main papilla and ampulla of Vater. In most instances, the minor duct of
Santorini becomes atretic or if patent, it enters into minor papilla.
Pancreas divisum, the most common congenital variant of the pancreatic anatomy, the ventral and dorsal pancreatic
ducts fail to fuse in utero, resulting in drainage of the bulk of pancreatic fluid (80-95%) via the duct of Santorini through
the relatively small minor papilla and predispose for pancreatitis.
ERCP is the standard of reference for imaging the pancreaticobiliary system because of its high image resolution and
the advantage of allowing therapeutic intervention 1 . ERCP, however, is expensive and invasive, with a reported complication
rate of 5%.
CT scan findings of pancreatic divisum include: the increase in the craniocaudal length of pancreas and the occasional
presence of a fat cleft separating the dorsal and ventral elements 2 .
MR cholangiopancreatography(MRCP) has been described as providing direct cholangiography and pancreatography
noninvasively and without use of contrast medium 3 . With use of a heavily T2-weighted pulse sequence, solid organs and
moving fluids have low signal intensity, and stationary fluids such as bile and pancreatic juice have high signal intensity.
Nonfusion of ventral and dorsal pancreatic ducts in pancreas divisum can be recognized more readily after secretinstimulated
MRCP. Exogenous administration of secretin stimulates the secretion of fluids and bicarbonates by the
exocrine pancreas, with a consequent increase in the volume of fluid inside the pancreatic ducts. This increase in fluid
content is used to improve the visualization of pancreatic ductal anatomy on MRCP.
Various endoscopic approaches used for the treatment of pancreas divisum with acute recurrent pancreatitis include
endoscopic sphincterotomy of the minor ampulla, with or without sphincterotomy of the major ampulla; ductal balloon
dilatation; and pancreatic duct stent placement.
REFERENCES
1. Frank HM, Ana L. K., Anubha W., et al. MRI of Pancreatitis and
Its Complications: Part 2, Chronic Pancreatitis. AJR 2004;
183:1645-52.
2. Soulen MC et al: Pancreatic divisum: CT scanning and ERCP
correlation. Radiology 1986:161;145.
3 Patrice MB, Caroline R, Patrice T, et al. Pancreas Divisum:
Evaluation with MR Cholangiopancreatography. Radiology 1996;
199:99-103.
4. Manfredi R, Costamagna G, Brizi MG, et al. Severe chronic
pancreatitis versus suspected pancreatic disease: dynamic MR
cholangiopancreatography after secretin stimulation.
Radiology 2000; 214(3):849-55.
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