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Year : 2022  |  Volume : 27  |  Issue : 5  |  Page : 655-656
 

Pancreatic divisum causing recurrent pancreatitis in an 8-year-old child


1 Department of Paediatric Surgery, AIIMS, Raipur, Chhattisgarh; Department of Paediatric Surgery, TNMC and BYL Nair Hospital, Mumbai, Maharashtra, India
2 Department of Paediatric Surgery, TNMC and BYL Nair Hospital, Mumbai, Maharashtra, India

Date of Submission17-Dec-2021
Date of Decision08-Mar-2022
Date of Acceptance07-Apr-2022
Date of Web Publication09-Sep-2022

Correspondence Address:
Hemanshi Shah
Department of Paediatric Surgery, TNMC and BYL Nair Hospital, Mumbai - 400 008, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaps.jiaps_249_21

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How to cite this article:
Tiwari C, Basu S, Makan A, Shah H. Pancreatic divisum causing recurrent pancreatitis in an 8-year-old child. J Indian Assoc Pediatr Surg 2022;27:655-6

How to cite this URL:
Tiwari C, Basu S, Makan A, Shah H. Pancreatic divisum causing recurrent pancreatitis in an 8-year-old child. J Indian Assoc Pediatr Surg [serial online] 2022 [cited 2022 Oct 3];27:655-6. Available from: https://www.jiaps.com/text.asp?2022/27/5/655/355799





   Case Summary Top


An 8-year-old boy presented with acute upper abdominal pain. He had the two episodes of similar pain in the past year, which was managed conservatively at an outside hospital. His serum lipase was found to be elevated; the rest of his blood investigations were normal. The diagnosis of relapsing acute pancreatitis was made.

Abdominal ultrasound suggested chronic calcific pancreatitis, dilated main pancreatic duct (7 mm), and no peripancreatic collection. Magnetic resonance cholangiopancreatography revealed chronic atrophic pancreatitis with dilated dorsal pancreatic duct and a calculus of 5 mm × 5 mm at the junction of the head and neck [Figure 1]. An endoscopic retrograde cholangiopancreatography (ERCP) with pancreaticogram from the minor papilla showed mildly dilated pancreatic duct to tail with multiple calculi within and presence of incomplete pancreatic divisum (PD) [Figure 2]. Minor papilla sphincterotomy was done and stones were extracted with basket performing a near-total ductal clearance. A 5-Fr stent was kept in the pancreatic duct which was removed after 6 weeks. The boy is asymptomatic for the past 5 years.
Figure 1: MRCP showing chronic atrophic pancreatitis with dorsal pancreatic duct and a calculus of 5 mm × 5 mm at the junction of head and neck. MRCP: Magnetic resonance cholangiopancreatography, MPD: Main pancreatic duct, CBD: Common bile duct

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Figure 2: ERCP done from minor papilla showing mildly dilated pancreatic duct upto tail with multiple calculi within and the presence of incomplete pancreatic divisum (Arrow). ERCP: Endoscopic retrograde cholangiopancreatography, MPD: Main pancreatic duct

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First described by Regnier Graff in 1664, PD is a congenital pancreatic duct anomaly which results from failure of fusion of dorsal and ventral pancreatic ducts during the 7th week of embryogenesis.[1],[2] Its incidence is 4%–14%, although lower (1%–2%) in the Asian population.[3] Three types have been described. In Type 1, there is a total failure of fusion between the two ducts; in Type 2, the ventral duct is completely absent; and in Type 3 (incomplete PD), wherein there is a small communication between the two ducts.[4] The inadequate drainage of the pancreas through the small dorsal duct through minor papilla results in the spectrum of diseases – relapsing acute pancreatitis, chronic pancreatitis, and pancreatic pain.[2] However, only 5% of the population becomes symptomatic for reasons unknown.[3]

A brief review of the literature in the same age group suggests that PD is a risk factor for acute recurrent pancreatitis and chronic pancreatitis in children independent of the genetic risk factors as per an analysis by Lin et al. in 52 patients with PD.[5] Endotherapy in the form of ERCP and sphincterotomy has been found to be safe and effective in the pediatric age group as per studies by Lin et al. (2019), Yan et al., Pan et al., Lin et al. (2021), and Wen et al. in 52, 1, 46, 27, and 38 pediatric patients, respectively.[2],[3],[5],[6],[7],[8],[9] In a study on seven patients, Snajdauf et al. reported improvement in three patients following ERCP, unsuccessful papillotomy in three patients, and recurrent pancreatitis requiring duodenum preserving pancreatic head resection in one patient.[10] Associations with choledochal cyst, abnormal pancreaticobiliary junction, and malrotation have also been reported.[11],[12],[13],[14] Our patient responded well to ERCP and has no complaints.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that patient's name and initials will not be published and due efforts will be made to conceal patient identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Stern CD. A historical perspective on the discovery of the accessory duct of the pancreas, the ampulla 'of Vater' and pancreas divisum. Gut 1986;27:203-12.  Back to cited text no. 1
    
2.
Farooqi R, Burke C, Chahal P, El-Khider F, Zahid U. Acute pancreatitis in pancreas divisum secondary to an impacted stone in the minor papilla. Cureus 2019;11:e5481.  Back to cited text no. 2
    
3.
Sarkar T, Jagroop S. A case of late presentation of pancreatic divisum in a patient with recurrent pancreatitis. Case Rep Med 2020;2020:3437465.  Back to cited text no. 3
    
4.
Türkvatan A, Erden A, Türkoğlu MA, Yener Ö. Congenital variants and anomalies of the pancreas and pancreatic duct: Imaging by magnetic resonance cholangiopancreaticography and multidetector computed tomography. Korean J Radiol 2013;14:905-13.  Back to cited text no. 4
    
5.
Lin TK, Abu-El-Haija M, Nathan JD, Palermo JP, Barth B, Bellin M, et al. Pancreas divisum in pediatric acute recurrent and chronic pancreatitis: Report from INSPPIRE. J Clin Gastroenterol 2019;53:e232-8.  Back to cited text no. 5
    
6.
Yan J, Zhang Z, Wang Z, Yu W, Xu X, Wang Y, et al. Pancreatic pseudocyst, pancreatitis, and incomplete pancreas divisum in a child treated with endotherapy: A case report. J Int Med Res. 2021; 49:1-7. doi: 10.1177/03000605211014395. PMID: 34038204; PMCID: PMC8161893..  Back to cited text no. 6
    
7.
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.  Back to cited text no. 7
    
8.
Lin TK, Pathak SJ, Hornung LN, Vitale DS, Nathan JD, Abu-El-Haija M. Clinical outcomes following therapeutic endoscopic retrograde cholangiopancreatography in children with pancreas divisum. J Pediatr Gastroenterol Nutr 2021;72:300-5.  Back to cited text no. 8
    
9.
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;19:834-41.  Back to cited text no. 9
    
10.
Snajdauf J, Petru O, Nahlovsky J, Rygl M, Frybova B, Bronsky J, et al. Pancreas divisum in children and duodenum-preserving resection of the pancreatic head. Eur J Pediatr Surg 2018;28:250-4.  Back to cited text no. 10
    
11.
Lei W, Yan J, Zhang T, Liu L, Chen Y. Pancreaticobiliary maljunction and pancreas divisum accompanied with intestinal malrotation: A case report. BMC Pediatr 2022;22:110.  Back to cited text no. 11
    
12.
Cui GX, Huang HT, Yang JF, Zhang XF. Rare variant of pancreaticobiliary maljunction associated with pancreas divisum in a child diagnosed and treated by endoscopic retrograde cholangiopancreatography: A case report. World J Clin Cases 2019;7:1073-9.  Back to cited text no. 12
    
13.
Sánchez Melgarejo JF, Rubio Mateos JM, Sánchez Fernández MJ. A degenerate Todani Ia choledochal cyst in a patient with pancreas divisum. Rev Esp Enferm Dig 2019;111:650-1.  Back to cited text no. 13
    
14.
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 2020;42:449-52.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2]



 

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