Journal of Indian Association of Pediatric Surgeons
Journal of Indian Association of Pediatric Surgeons
                                                   Official journal of the Indian Association of Pediatric Surgeons                           
Year : 2022  |  Volume : 27  |  Issue : 5  |  Page : 655--656

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


Charu Tiwari1, Syamantak Basu2, Apoorva Makan2, Hemanshi Shah2,  
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

Correspondence Address:
Hemanshi Shah
Department of Paediatric Surgery, TNMC and BYL Nair Hospital, Mumbai - 400 008, Maharashtra
India




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;27:655-656


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 Dec 1 ];27:655-656
Available from: https://www.jiaps.com/text.asp?2022/27/5/655/355799


Full Text



 Case Summary



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}{Figure 2}

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

1Stern 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.
2Farooqi 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.
3Sarkar T, Jagroop S. A case of late presentation of pancreatic divisum in a patient with recurrent pancreatitis. Case Rep Med 2020;2020:3437465.
4Türkvatan 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.
5Lin 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.
6Yan 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..
7Pan 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.
8Lin 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.
9Wen 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.
10Snajdauf 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.
11Lei 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.
12Cui 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.
13Sánchez 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.
14Cicero 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.