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Pancreatic Divisum

Updated : May 27, 2024





Background

Pancreatic divisum is a congenital anatomical variation in the human pancreas that occurs when the ducts responsible for draining digestive enzymes from the pancreas do not properly fuse during fetal development. The pancreas develops typically from two separate primordial ducts—the ventral and dorsal ones.

These ducts should fuse to form a single main pancreatic duct (Wirsung’s duct) that allows the release of digestive enzymes into the duodenum. However, in cases of pancreatic divisum, this fusion does not occur, resulting in two separate ducts: the central pancreatic duct and a smaller accessory duct.

Epidemiology

Pancreatic divisum is relatively common and is estimated to occur in about 5-15% of the population. In most cases, it does not cause any symptoms or health issues and may go undetected throughout a person’s life. Pancreatic divisum is present from birth, but it may not necessarily lead to symptoms or complications in all individuals.

Symptoms, if they occur, can develop at any age. There doesn’t appear to be a significant gender difference in the prevalence of pancreatic divisum. It affects both males and females equally. Some studies have suggested that the prevalence of pancreatic divisum may vary among different ethnic groups and populations. However, more research is needed to confirm these potential variations.

Anatomy

Pathophysiology

In individuals with pancreatic divisum, the dorsal pancreatic duct and ventral pancreatic duct remain separate instead of merging to form a single main pancreatic duct. This can result in a reduced or inefficient drainage of pancreatic enzymes and fluids into the duodenum, the first part of the small intestine. The smaller dorsal duct often drains a portion of the pancreatic juices produced by the pancreas.

Because this duct is smaller and less efficient in draining secretions compared to a single main duct, there can be stasis of digestive enzymes and fluids within the dorsal duct. Stagnation of pancreatic secretions in the dorsal duct can lead to the development of recurrent acute pancreatitis or even chronic pancreatitis in some cases. This is because the retained pancreatic enzymes can activate prematurely within the duct, leading to autodigestion of the pancreas and inflammation.

Etiology

Genetic Factors: While the exact cause of the failure of fusion between the pancreatic ducts is not always clear, there may be genetic factors that play a role in the development of pancreatic divisum. Research has suggested that certain genetic mutations or variations may be associated with an increased risk of congenital pancreatic abnormalities, including divisum.

Abnormal Fusion: In individuals with pancreatic divisum, the dorsal, and ventral pancreatic ducts fail to fuse properly during development. They remain separate instead of merging to form a single main pancreatic duct. This failure of fusion leads to the persistence of two distinct ducts, known as pancreatic divisum.

Genetics

Prognostic Factors

Clinical History

Pancreatic divisum is present from birth (congenital), so the clinical history may include information about when the patient first experienced symptoms or complications related to the condition. A family history of pancreatitis or pancreatic issues may be relevant, as genetic factors could contribute to the development of congenital pancreatic anomalies like divisum.

The clinical history may include information about any previous episodes of pancreatitis, abdominal pain, or other symptoms associated with pancreatic divisum. One of the most common symptoms associated with pancreatic divisum is recurrent abdominal pain, often in the upper abdomen. Patients may experience nausea and vomiting, especially during episodes of pancreatitis.

Recurrent acute pancreatitis is a significant symptom and complication of pancreatic divisum, characterized by severe abdominal pain, fever, and elevated pancreatic enzyme levels. Chronic pancreatitis associated with pancreatic divisum can lead to malabsorption of nutrients and weight loss. The duration of symptoms and complications associated with pancreatic divisum can vary. Some individuals may have isolated episodes of pancreatitis, while others may experience chronic or recurrent symptoms that persist over a longer period.

Physical Examination

In individuals experiencing acute pancreatitis due to pancreatic divisum, a healthcare provider may find tenderness upon palpation of the upper abdomen. The tenderness is typically localized to the area where the pancreas is located. Severe abdominal pain associated with pancreatitis can lead to guarding (muscle tensing) or rigidity of the abdominal muscles.

This is a protective response to pain and can be detected during the examination. In rare cases, pancreatic divisum can lead to complications such as obstructive jaundice.

Chronic pancreatitis associated with pancreatic divisum can lead to malabsorption of nutrients. Signs of malnutrition, such as muscle wasting, weight loss, and vitamin deficiencies, may be evident upon physical examination. Elevated heart rate, fever, and low blood pressure may be observed in individuals experiencing an acute episode of pancreatitis.

Age group

Associated comorbidity

Associated activity

Acuity of presentation

Differential Diagnoses

Acute Pancreatitis

Biliary Tract Disease

Functional Abdominal Pain Syndrome

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

Lifestyle Modification

If alcohol consumption or smoking contributes to pancreatitis, quitting these habits is essential to prevent further damage to the pancreas. Maintaining a healthy weight and following a balanced diet can help reduce the risk of complications.

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

In some cases, surgery may be necessary to create a direct connection between the pancreatic ducts and the small intestine (pancreaticojejunostomy). This procedure aims to improve drainage and reduce the risk of pancreatitis.

In severe cases of recurrent pancreatitis or complications such as pseudocysts, partial or total pancreatectomy may be considered, but it is usually a last resort due to the potential for diabetes and other long-term complications.

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

Medication

Media Gallary

References

Pancreatic Divisum

Updated : May 27, 2024




Pancreatic divisum is a congenital anatomical variation in the human pancreas that occurs when the ducts responsible for draining digestive enzymes from the pancreas do not properly fuse during fetal development. The pancreas develops typically from two separate primordial ducts—the ventral and dorsal ones.

These ducts should fuse to form a single main pancreatic duct (Wirsung’s duct) that allows the release of digestive enzymes into the duodenum. However, in cases of pancreatic divisum, this fusion does not occur, resulting in two separate ducts: the central pancreatic duct and a smaller accessory duct.

Pancreatic divisum is relatively common and is estimated to occur in about 5-15% of the population. In most cases, it does not cause any symptoms or health issues and may go undetected throughout a person’s life. Pancreatic divisum is present from birth, but it may not necessarily lead to symptoms or complications in all individuals.

Symptoms, if they occur, can develop at any age. There doesn’t appear to be a significant gender difference in the prevalence of pancreatic divisum. It affects both males and females equally. Some studies have suggested that the prevalence of pancreatic divisum may vary among different ethnic groups and populations. However, more research is needed to confirm these potential variations.

In individuals with pancreatic divisum, the dorsal pancreatic duct and ventral pancreatic duct remain separate instead of merging to form a single main pancreatic duct. This can result in a reduced or inefficient drainage of pancreatic enzymes and fluids into the duodenum, the first part of the small intestine. The smaller dorsal duct often drains a portion of the pancreatic juices produced by the pancreas.

Because this duct is smaller and less efficient in draining secretions compared to a single main duct, there can be stasis of digestive enzymes and fluids within the dorsal duct. Stagnation of pancreatic secretions in the dorsal duct can lead to the development of recurrent acute pancreatitis or even chronic pancreatitis in some cases. This is because the retained pancreatic enzymes can activate prematurely within the duct, leading to autodigestion of the pancreas and inflammation.

Genetic Factors: While the exact cause of the failure of fusion between the pancreatic ducts is not always clear, there may be genetic factors that play a role in the development of pancreatic divisum. Research has suggested that certain genetic mutations or variations may be associated with an increased risk of congenital pancreatic abnormalities, including divisum.

Abnormal Fusion: In individuals with pancreatic divisum, the dorsal, and ventral pancreatic ducts fail to fuse properly during development. They remain separate instead of merging to form a single main pancreatic duct. This failure of fusion leads to the persistence of two distinct ducts, known as pancreatic divisum.

Pancreatic divisum is present from birth (congenital), so the clinical history may include information about when the patient first experienced symptoms or complications related to the condition. A family history of pancreatitis or pancreatic issues may be relevant, as genetic factors could contribute to the development of congenital pancreatic anomalies like divisum.

The clinical history may include information about any previous episodes of pancreatitis, abdominal pain, or other symptoms associated with pancreatic divisum. One of the most common symptoms associated with pancreatic divisum is recurrent abdominal pain, often in the upper abdomen. Patients may experience nausea and vomiting, especially during episodes of pancreatitis.

Recurrent acute pancreatitis is a significant symptom and complication of pancreatic divisum, characterized by severe abdominal pain, fever, and elevated pancreatic enzyme levels. Chronic pancreatitis associated with pancreatic divisum can lead to malabsorption of nutrients and weight loss. The duration of symptoms and complications associated with pancreatic divisum can vary. Some individuals may have isolated episodes of pancreatitis, while others may experience chronic or recurrent symptoms that persist over a longer period.

In individuals experiencing acute pancreatitis due to pancreatic divisum, a healthcare provider may find tenderness upon palpation of the upper abdomen. The tenderness is typically localized to the area where the pancreas is located. Severe abdominal pain associated with pancreatitis can lead to guarding (muscle tensing) or rigidity of the abdominal muscles.

This is a protective response to pain and can be detected during the examination. In rare cases, pancreatic divisum can lead to complications such as obstructive jaundice.

Chronic pancreatitis associated with pancreatic divisum can lead to malabsorption of nutrients. Signs of malnutrition, such as muscle wasting, weight loss, and vitamin deficiencies, may be evident upon physical examination. Elevated heart rate, fever, and low blood pressure may be observed in individuals experiencing an acute episode of pancreatitis.

Acute Pancreatitis

Biliary Tract Disease

Functional Abdominal Pain Syndrome

Lifestyle Modification

If alcohol consumption or smoking contributes to pancreatitis, quitting these habits is essential to prevent further damage to the pancreas. Maintaining a healthy weight and following a balanced diet can help reduce the risk of complications.

In some cases, surgery may be necessary to create a direct connection between the pancreatic ducts and the small intestine (pancreaticojejunostomy). This procedure aims to improve drainage and reduce the risk of pancreatitis.

In severe cases of recurrent pancreatitis or complications such as pseudocysts, partial or total pancreatectomy may be considered, but it is usually a last resort due to the potential for diabetes and other long-term complications.