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Rare variant of pancreaticobiliary maljunction associated with pancreas divisum in a child diagnosed and treated by endoscopic retrograde cholangiopancreatography: A case report

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World Journal of Clinical Cases 2019年第9期7卷 1073-1079页

作者： Guang-Xing Cui Hai-Tao Huang Jian-Feng Yang Xiao-Feng Zhang Department of Gastroenterology Affiliated Hangzhou First People’s Hospital Zhejiang University School of Medicine

BACKGROUND Pancreaticobiliary maljunction(PBM) is an uncommon congenital anomaly of the pancreatic and biliary ductal system, defined as a union of the pancreatic and biliary ducts located outside the duodenal wall. According to the Komi classification of PBM, the common bile duct(CBD) directly fuses with the ventral pancreatic duct in all types. Pancreas divisum(PD) occurs when the ventral and dorsal ducts of the embryonic pancreas fail to fuse during the second month of fetal development. The coexistence of PBM and PD is an infrequent condition.Here, we report an unusual variant of PBM associated with PD in a pediatric patient, in whom an anomalous communication existed between the CBD and dorsal pancreatic duct.CASE SUMMARY A boy aged 4 years and 2 mo was hospitalized for abdominal pain with nausea and jaundice for 5 d. Abdominal ultrasound showed cholecystitis with cholestasis in the gallbladder, dilated middle-upper CBD, and a strong echo in the lower CBD, indicating biliary stones. The diagnosis was extrahepatic biliary obstruction caused by biliary stones, which is an indication for endoscopic retrograde cholangiopancreatography(ERCP). ERCP was performed to remove biliary stones. During the ERCP, we found a rare communication between the CBD and dorsal pancreatic duct. After clearing the CBD with a balloon, an 8.5 Fr 4-cm pigtail plastic pancreatic stent was placed in the biliary duct through the major papilla. Six months later, his biliary stent was removed after he had no symptoms and normal laboratory tests. In the following 4-year period, the child grew up normally with no more attacks of abdominal pain.CONCLUSION We consider that ERCP is effective and safe in pediatric patients with PBM combined with PD, and can be the initial therapy to manage such cases,especially when it is combined with aberrant communication between the CBD and dorsal pancreatic duct.

关键词： Pancreaticobiliary maljunction Pancreas divisum Endoscopic retrograde cholangiopancreatography Variant Communication Children Case report

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Diagnosis and treatment of pancreas divisum: A literature review

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Hepatobiliary & Pancreatic Diseases International 2019年第4期18卷 332-336页

作者： Valentina Ferri Emilio Vicente Yolanda Quijano Benedetto Ielpo Hipolito Duran Eduardo Diaz Isabel Fabra Riccardo Caruso Division of General Surgery Sanchinarro Hospital San Pablo University

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.

关键词： Pancreas divisum Duodenal-preserving pancreatectomy Chronic pancreatitis Recurrent acute pancreatitis

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Pancreatitis in patients with pancreas divisum:Imaging features at MRI and MRCP

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World Journal of Gastroenterology 2013年第30期19卷 4907-4916页

作者： Deng-Bin Wang Jinxing Yu Ann S Fulcher Mary A Turner Department of Radiology Xinhua HospitalShanghai Jiao Tong University School of Medicine Department of Radiology Virginia Commonwealth UniversityMedical College of VirginiaRichmondVA 23298-0615United States

AIM:To determine the magnetic resonance cholangiopancreatography(MRCP)and magnetic resonance imaging(MRI)features of pancreatitis with pancreas divisum(PD)and the differences vs pancreatitis without divisum.METHODS:Institutional review board approval was obtained and the informed consent requirement was waived for this HIPAA-compliant study.During one year period,1439 consecutive patients underwent successful MRCP without injection of secretin and abdominal MRI studies for a variety of clinical indications using a 1.5 T magnetic resonance scanner.Two experienced radiologists retrospectively reviewed all the studies in consensus.Disputes were resolved via consultation with a third experienced radiologist.The assessment included presence and the imaging findings of PD,pancreatitis,and distribution of abnormalities.The pancreatitis with divisum constituted the study group while the pancreatitis without divisum served as the control group.MRCP and MRI findings were correlated with final diagnosis.Fisher exact tests and Pearson × 2 tests were performed.RESULTS:Pancreatitis was demonstrated at MRCP and MRI in 173 cases(38 cases with and 135 cases without divisum)among the 1439 consecutive cases.The recurrent acute pancreatitis accounted for 55.26%(21 of 38)in pancreatitis patients associated with PD,which was higher than 6.67%(9 of 135)in the control group,whereas the chronic pancreatitis was a dominant type in the control group(85.19%,115 of 135)when compared to the study group(42.11%,16 of 38)(χ 2 = 40.494,P divisum.Recurrent acute pancreatitis and isolated dorsal involvement are more common in patients with divisum.

关键词： Pancreas divisum Pancreatitis Diagnosis Magnetic resonance imaging Magnetic resonance cholangiopancreatography

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Research advance in the diagnosis of pancreas divisum

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Health 2010年第12期2卷 1401-1404页

作者： Zong-fu Zheng Qi-cai Liu 不详

Pancreas divisum is a kind of congenital anatomic abnormality;its diagnostic basis depends mainly on imaging examination. With the development of medical science, imaging technology has been improved and added, and a complete examination system including ERCP, B-Ultrasound, MRCP, S-MRCP and CT, etc. has been formed. There are even researcher, through further analysis of pancreas divisum on the level of genes, found that CFTR is a risk factor causing such disease. This paper is focused on the value of these examination methods in the diagnosis of pancreas divisum.

关键词： Pancreas divisum Endoscopic Retrograde Cholangiopancreatography (EPCR) Magnetic Resonance Cholangiopancreatography (MRCP) Computed Tomography (CT) Cystic Fibrosis Transmembrane Conductance Regulator (CFTR)

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Clinical implications of accessory pancreatic duct

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World Journal of Gastroenterology 2010年第36期16卷 4499-4503页

作者： Terumi Kamisawa Kensuke Takuma Taku Tabata Naoto Egawa Department of Internal Medicine Tokyo Metropolitan Komagome Hospital3-18-22 HonkomagomeBunkyo-kuTokyo 113-8677Japan

The accessory pancreatic duct (APD) is the main drainage duct of the dorsal pancreatic bud in the embryo,entering the duodenum at the minor duodenal papilla (MIP).With the growth,the duct of the dorsal bud undergoes varying degrees of atrophy at the duodenal end.Patency of the APD in 291 control cases was 43% as determined by dye-injection endoscopic retrograde pancreatography.Patency of the APD in 46 patients with acute pancreatitis was only 17%,which was significantly lower than in control cases (P < 0.01).The terminal shape of the APD was correlated with APD patency.Based on the data about correlation between the terminal shape of the APD and its patency,the estimated APD patency in 167 patients with acute pancreatitis was 21%,which was signif icantly lower than in control cases (P < 0.01).A patent APD may function as a second drainage system for the main pancreatic duct to reduce the pressure in the main pancreatic duct and prevent acute pancreatitis.Pancreatographic f indings of 91 patients with pancreaticobiliary maljunction (PBM) were divided into a normal duct group (80 patients) and a dorsal pancreatic duct (DPD) dominant group (11 patients).While 48 patients (60%) with biliary carcinoma (gallbladder carcinoma,n=42;bile duct carcinoma,n=6) were identified in PBM with a normal pancreatic duct system,only two cases of gallbladder carcinoma (18%) occurred in DPD-dominant patients (P < 0.05).Concentration of amylase in the bile of DPD dominance was signifi cantly lower than that of normal pancreatic duct system (75 403.5 ± 82 015.4 IU/L vs 278 157.0 ± 207 395.0 IU/L,P < 0.05).In PBM with DPD dominance,most pancreatic juice in the upper DPD is drained into the duodenum via the MIP,and reflux of pancreatic juice to the biliary tract might be reduced,resulting in less frequency of associated biliary carcinoma.

关键词： Accessory pancreatic duct Minor duodenal papilla Pancreas divisum Main pancreatic duct Acute pancreatitis Pancreaticobiliary maljunction

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Duodenal duplication cyst and pancreas divisum causing acute pancreatitis in an adult male

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World Journal of Gastrointestinal Endoscopy 2010年第9期2卷 318-320页

作者： Eduardo Redondo-Cerezo Julio Pleguezuelo-Díaz Mercedes López de Hierro José F Macias-Sánchez Cristina Violo Ubia María Del Mar Martín-Rodríguez Javier De TeresaGalván Endoscopy Unit Gastroenterology DepartmentHospital Universitario Virgen de las NievesAvenida de las Fuerzas Armadas 2Granada 18014Spain

Duodenal duplication cysts are rare congenital abnormalities which are more commonly diagnosed in infancy and childhood.However,in rare cases,these lesions can remain asymptomatic until adulthood.The combination of duplication cyst and pancreas divisum is extremely rare and both conditions have been linked with acute recurrent pancreatitis.We present the case of a 37 years-old patient who presented with repeated episodes of acute pancreatitis.By means of magnetic resonance imaging and endoscopic ultrasonography we discovered a duplication cyst whose cavity received drainage from the dorsal pancreas.After opening the cyst cavity to the duodenal lumen with a needle knife the patient presented no further episodes in the clinical follow-up.Comparable literature findings and therapeutic options for these abnormalities are discussed with regard to the presented case.

关键词： Duplication cyst Pancreas divisum Acute recurrent pancreatitis Endoscopic ultrasonography

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有胰 divisum 的 Choledochocele : 在磁性的回声 cholangiopancreatography 上诊断的稀罕同现

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World Journal of Radiology 2013年第7期5卷 264-266页

作者： Yashwant Patidar Nitesh Agarwal Shailesh Gupta Ankur Arora Amar Mukund S Rajesh Department of Radiology Institute of Liver and Biliary Sciences New Delhi 110070 India

We report a case of a 42-year-old male with symptomatic choledochocele and incidental pancreas divisum diagnosed with magnetic resonance cholangiopancreatography (MRCP). Small choledochocele is rare congenital malformation associated with non-specific symptoms and a delay in diagnosis. The coexistence of choledochocele and pancreas divisum is extremely rare with only two case reports published in literature. In both cases MRCP failed to diagnose any biliary or pancreatic abnormality. This case suggests that the patients with recurrent abdominal pain and pancreas divisum should not be presumed to be suffering from pancreatitis. Careful evaluated for additional anomalies in the biliary tree should be sought for refractory symptoms. MRCP is a useful one-stop-shop for diagnosing pancreatic and biliary ductal anomalies.

关键词： Choledochocele Pancreas divisum Magnetic resonance cholangiopan-creatography Pancreaticand biliary ductal anomalies Pancreatitis

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Endoscopic approach through the minor papilla for the management of pancreatic diseases

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World Journal of Gastrointestinal Endoscopy 2013年第3期5卷 81-88页

作者： Nao Fujimori Hisato Igarashi Akira Asou Ken Kawabe Lingaku Lee Takamasa Oono Taichi Nakamura Yusuke Niina Masayuki Hijioka Masahiko Uchida Kazuhiro Kotoh Kazuhiko Nakamura Tetsuhide Ito Ryoichi Takayanagi Department of Medicine and Bioregulatory Science Graduate School of Medical SciencesKyushu UniversityHigashi-kuFukuoka 812-8582Japan Department of Gastroenterology National Hospital OrganizationKyushu Medical CenterChuou-kuFukuoka 810-8563Japan

AIM:To clarify the efficacy and safety of an endoscopic approach through the minor papilla for the management of pancreatic diseases.METHODS:This study included 44 endoscopic retrograde cholangiopancreatography(ERCP) procedures performed in 34 patients using a minor papilla approach between April 2007 and March 2012.We retrospectively evaluated the clinical profiles of the patients,the endoscopic interventions,short-term outcomes,and complications.RESULTS:Of 44 ERCPs,26 were diagnostic ERCP,and 18 were therapeutic ERCP.The most common cause of difficult access to the main pancreatic duct through the major papilla was pancreas divisum followed by distortion of Wirsung's duct.The overall success rate of minor papilla cannulation was 80%(35/44),which was significantly improved by wire-guided cannulation(P = 0.04).Endoscopic minor papillotomy(EMP) was performed in 17 of 34 patients(50%) using a needle-knife(13/17) or a pull-type papillotome(4/17).EMP with pancreatic stent placement,which was the main therapeutic option for patients with chronic pancreatitis,recurrent acute pancreatitis,and pancreatic pseudocyst,resulted in short-term clinical improvement in 83% of patients.Mild post-ERCP pancreatitis occurred as an early complication in 2 cases(4.5%).CONCLUSION:The endoscopic minor papilla approach is technically feasible,safe,and effective when the procedure is performed in a high-volume referral center by experienced endoscopists.

关键词： Endoscopic papillotomy Endoscopic retrograde cholangiopancreatography Minor papilla Pancreas divisum Pancreatitis

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