Symptomatic Pancreas Divisum: Recurrent Acute Pancreatitis in a 23-Year-Old Man

Authors:
John H. Rosenberg, BS; John H. Werner, BS; and Shailendra K. Saxena, MD, PhD

Citation:
Rosenberg JH, Werner JH, Saxena SK. Symptomatic pancreas divisum: recurrent acute pancreatitis in a 23-year-old man. Consultant. 2018;58(10):274-278.

A 23-year-old white man presented to the emergency department with nonradiating epigastric abdominal pain accompanied by nausea and vomiting for 2 to 3 days. He rated his pain as 10 of 10 in intensity on admission, and he had several episodes of vomiting prior to arrival. He had had at least 4 episodes of acute pancreatitis in the 18 months prior to admission, all with a similar presentation.

The patient reported occasional social drinking, and he smoked cigarettes. He denied known allergies and took no medication prior to admission. His case was managed symptomatically with intravenous fluids, narcotic analgesia, and antiemetics until his pain had resolved and he could tolerate a regular diet on day 3. The patient was discharged on day 5 to his home with a diagnosis of recurrent acute pancreatitis and was referred to a gastroenterologist for further outpatient workup.

Physical examination. Vital signs at the time of admission were as follows: blood pressure, 131/78 mm Hg; temperature, 36.9°C; pulse, regular at 66 beats/min; and respiratory rate, 20 breaths/min. Auscultation of his abdomen demonstrated decreased bowel sounds, while palpation of his abdomen demonstrated diffuse tenderness, with maximum tenderness located in the epigastric area.

Diagnostic tests. The patient’s laboratory test values on his most recent admission are shown in the accompanying Table, along with the values from subsequent admissions for the same symptom of epigastric pain.

The gastroenterologist saw the patient for an esophagogastroduodenoscopy 1 month after discharge. A duodenal aspirate was positive for cholesterol crystals, and the etiology of his recurrent acute pancreatitis was thought to be microlithiasis. It was recommended that the patient undergo a laparoscopic cholecystectomy. The results of a computed tomography (CT) scan of the abdomen showed peripancreatic fluid, fat stranding, and fluid extending into the pelvis, all signs suggestive of acute pancreatitis. A laparoscopic cholecystectomy was performed 5 months from the time of the initial hospital admission.

The patient had been abstinent from alcohol for 1 year prior to cholecystectomy, and he did not return to the hospital until 2 years after cholecystectomy, when he presented with 1 day of abdominal pain localized to the epigastric area. The pain radiated to the back and was described as 7 of 10 in intensity. He denied nausea, vomiting, fever, or chills. He reported that the pain was similar to that experienced prior to cholecystectomy.

The gastroenterologist recommended a magnetic resonance cholangiopancreatography (MRCP) scan, which failed to demonstrate any abnormalities. The patient’s pain was addressed by providing bowel rest via nil per os diet, intravenous fluids, and pantoprazole until his pain subsided. He was discharged on high-dose pancrelipase, omeprazole, oxycodone, and tramadol.

The patient underwent endoscopic retrograde cholangiopancreatography (ERCP) 1 month later. Attempts to obtain a pancreatogram through the major papilla using a standard catheter and guide wire failed. A prominent minor papilla was identified. Attempts to cannulate the minor papilla before and after secretin administration using an ERCP catheter failed. No output of pancreatic juice was seen after secretin administration. 

The strong suspicion of pancreas divisum led to a minor papilla precut sphincterotomy. The pancreatic duct was cannulated though the minor papilla, and complete pancreatogram was obtained, the results of which were diagnostic for the presence of pancreas divisum.

The patient had agreed to receive a 3F pancreatic stent rather than a 5F stent. An 8-cm long pancreatic stent was placed over a 0.018-inch diameter guidewire. The minor papilla precut was extended. There was no bleeding during the procedure. No cholangiogram was obtained following the procedure.