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Pancreas Divisum Pak Armed Forces Med J 2009; 59(3): 385-7

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Pancreas Divisum Pak Armed Forces Med J 2009; 59(3): 385-7 Pancreas Divisum Pak Armed Forces Med J 2009; 59(3): 385- PANCREAS DIVISUM Muhammad Saeed, Iftikhar Ahmed, Hussain Rashid Ihsan, Taimor Hussain Babar, Shakeel Sar"ar, Na#eed Ashrarf !om"ined Mi#i$ar% &os'i$al (ue$$a INTR$DUCTI$N *rom $he age o* $-o %ears *or -hich he -as Pancreas divisum is $he mos$ common treated s%m'$omapticall%+ >e had laparo$om% congenital anomal% o* $he 'ancreatic *our %ears ago *or same com'laints+ ,$ -as anatom%+ ,$ occurs -hen $he ductal s%stems o* ne)ative and ap'endectom% -as done+ 4n $he ventral and dorsal 'ancreatic ducts *ail $o '&%sical e3amination &e -as 'ale1 'ulse rate *use ./0+ As a resu#$ o* nonunion o* $he ducts1 -as 120/ min, $em'erature 37C1 @lood a ma2or 'ortion o* 'ancreatic e3ocrine 'ressure 110? 70 mm >) and res'irator% rate secretions enter $he duodenum via $he dorsal 22/min. :enderness -as 'ositive in duct and minor 'apilla. 4"struction $o e'igastrium -it& slu))is& "o-e# sounds+ 'ancreatic e3ocrine secre$or% flo- $hrou)& Ches$ -as clear and hear$ sounds -ere $he minor duct and minor 'apilla can resu#$ in normal. 'ancreatitis in a small num"er o* 'atients A"dominal ultrasound revealed multiple -it& 'ancreas divisum .2]+ ,ncom'lete or small cysts -it& 'ro"e $enderness in 'artial divisum is de6ned as $he 'ancreatic re)ion. 9o ascites -as seen+ !: communication o* $he dorsal and ventral scan o* $he a"domen sho-ed )ross#% dilated ducts via a tin% "ranch. Mos$ 'eo'le -it& 'ancreatic duct (Fig+ 1)+ Aes$ o* $he abdominal anomalous 'ancreatic ductal s%s$ems are stud% -as normal. Patient under-ent as%m'$omatic; ho-ever1 a significant num"er e3'lorator% laparo$om%+ 4'erative o* 'atients 'resen$ -it& recurrent attacks o* cholangio)ram sho-ed 'ancreatic divisum acute 'ancreatitis .3]+ ,n 'atients -it& -it& unfused s%stems o* $he ventral and 'ancreas divisum1 'ancreatic his$or% has dorsal 'ancreatic ducts+ Pancreatic duct -as demonstrated changes o* chronic 'ancreatitis )ross#% dilated ap'roaching size o* in $he dorsal duct distribution and normal duodenum (Fig+ 2)+ 4"struction $o 'ancreatic 'arench%ma in $he ventral duct distribution. flo- $hrou)& $he duct and minor 'apilla ,$ is o"served in 78 o* normal 'ersons at resulted in 'ancreatitis and "o% 'resented au$o's%+ 9o racial 'redominance e3ists+ :he -it& recurrent attacks o* acute 'ancreatitis+ male-$o-*emale ratio is /:/+ Median age at Changes o* chronic 'ancreatitis seen in $he diagnosis is 5- %ears .;0+ ,n 1642, <irsung dorsal duct distribution. :rans duodenal demonstrated $he main 'ancreatic duct1 and s'hintero'las$% -it& stenting done $o drain in 1775, =antorini accurate#% described $he o"structed 'ancreatic duct. Patient made un- ductal anatom% and demonstrated $he eventfu# recover% in 'os$ o'erative -ard+ >e accessor% 'ancreatic duct .5]+ -as dischar)ed s%m'$om *ree *rom $he CASE REP$RT hos'ital one -eek later+ =tent removed after / mont&+ Patient had no e'isode o* 'ain during A 12 %ear old "o% -as admitted $o $he last $hree months+ sur)ical -ard -it& com'laints o* e'igastric 'ain and vomiting *or $-o da%s+ :here -as no DISCUSSI$N his$or% o* 'rolonged dru) intake or :he 'resence o* clear-cu$ 'ancreatitis in abdominal trauma. >e had significant 'as$ association -it& 'ancreas divisum makes it his$or% o* recurrent u''er abdominal 'ain easier $o determine $hat $he 'ancreas is $he site o* origin o* $he abdominal 'ain. ,n Corres%onden&e: Ma2 Mu&ammad =aeed1 !#assi6ed129 Aadio#o)is$1 CM> Quet$a. Received: 19 July 2008; Accepted: 19 Sep 2008 Pancreas Divisum Pak Armed Forces Med J 2009; 59(3): 385- 'atients -it& divisum -ho do no$ intervention in 'atients -it& 'ancreas demonstrate clinical 'ancreatitis1 $he e3istence divisum+ o* accessor% 'apilla stenosis is $o "e =ingle or multislice helical com'uted determined+ Cndosco'ic retro)rade $omo)rap&% (!:) occasionall% can de'ict cholangio'ancreato)rap&% (CACP) is $he $es$ 'ancreas divisum -it& /-3 mm collimation1 o* choice *or making a diagnosis o* 'ancreas overlap'ing reconstructions1 and $he use o* divisum .70+ CACP is e3'ensive and invasive1 -ater as a ne)ative contras$ agent 'rovide -it& a re'orted com'lication rate o* 5%+ high-Euality images amenable $o $hree- Criteria *or $he diagnosis o* 'ancreas divisum dimensional (3D) re*ormations+ While demonstration o* ductal anatom% "% !: is more difficu#$ $han demonstration o* )ross )landular architecture+ !: criterion *or $he diagnosis o* 'ancreas divisum is visualization o* $he nonunion o* $he dorsal and ventral ducts directl% 2oining $he common "ile duct+ Additional evidence is $he visualization o* a *at-attenuation cle*$ se'arating $he 'ancreatic head *rom $he 'ancreatic "od%+ Geman . 0 de6nitive#% identif% se'arate dorsal and (i)* +' CT s&an representing )ross!, di!ated pancreati& ventral ducts in onl% 5 o* 12 'atients -it& duct* kno-n 'ancreas divisum+ Magnetic resonance cholangio'anc- reato)rap&% (MACP) is a noninvasive imaging modality $hat de'icts abnormalities o* $he "iliar% and $he 'ancreatic ducts and 'arench%mal structures+ MACP (-it& or -ithou$ secretin) -ill like#% re'lace CACP *or diagnostic 'ur'oses in $he near *uture+ :he use o* secretin increases $he cos$ o* MA, e3amination "ecause o* $he cos$ o* $he dru) and $he additional imaging $ime+ =ecretin (i)* -' $%erati#e &ho!an)io)ram* Sho"ing )ross!, stimulates $he secretion o* fluids "% $he di!oted Pancreati& duct* PD. Pancreati& duct, CBD. e3ocrine 'ancreas1 -it& a conseEuen$ increase Common bi!e duct in $he volume o* fluid inside $he 'ancreatic on CA!P are cannulation o* $he am'ulla o* ducts+ :his im'roves $he visualization o* Dater1 -hich allo-s 6lling o* a shor$ (10-60 'ancreatic ductal anatom% on MACP+ mm) and $hin (2-mm diame$er) main 9onunion o* ventral and dorsal 'ancreatic 'ancreatic duct, located in a 'osterior ducts in 'ancreas divisum can "e reco)nized 'osition. Cannulation o* $he accessor% 'apilla more readil% after secretin-stimulated MACP+ (allo-s 6lling o* a lar)er duct, 2-; mm in :he amount o* fluid secreted into $he diameter)1 -hich drains almos$ $he entire duodenum can also "e Euantified+ Man*redi 'ancreas *rom $he tail $o $he anterior 'ar$ o* .8] identi6ed 'ancreas divisum in 8 o* $he head+ CACP is also used *or $herapeutic 'atients (7 o* 84) "% MACP "e*ore secretin administration and in /;8 o* 'atients (12 o* 130 Pancreas Divisum Pak Armed Forces Med J 2009; 59(3): 385- 84) *ollo-ing secretin administration. Aecent RE(ERENCES develo'ment o* half-Fourier 'ulse seEuences /+ Mer)ener I1 Iozarek AA+ :&erapeu$ic 'ancreatic and 'hased-arra% sur*ace coils enables $he endosco'%+ Endosco'% 2005; 37: 201-7. acquisition o* high-Euality images during 2. 9eu&aus >+ :&erapeu$ic 'ancreatic endosco'%+ "reat& holding1 -it& a hig& signal-$o-noise Cndosco'% 2004; 36: 8-16. 3. 3.Kamisa-a :1 C)a-a 91 :u J+ Pancreato)rap&ic ratio+ @re$ .9] identi6es 'ancreas divisum in 7 inves$i)ation o* em"r%o#o)% o* com'#e$e and incom'#e$e o* //; MACP e3aminations using a "od% coil 'ancreas divisum. Pancreas 2007; 34:96-102. ;+ ='icak J1 Pou#ova P1 P#ucnarova J+ Pancreas divisum and 19 o* 154 MACP e3aminations using a does no$ modi*% $&e natural course o* c&ronic 'ancreati$is. J $orso coil+ Kas$roen$ero# 2007; 42:135-9. 5. Cr$an A+ Lon)-$erm resu#$s af$er endosco'ic =ecretin-stimulated ultrasound (H=) is a 'ancreatic s$en$ '#acemen$ -i$&ou$ 'ancreatic 'api##o$om% noninvasive tes$ $hat sho-s )reat 'romise in acu$e recurren$ 'ancreati$is due $o 'ancreas divisum+ Kas$roin$es$ Endosc 2000; 52:9-/;+ .10]+:he tes$ invo#ves seEuential sono)raphic 7+ A#azmi <M1 Mosler P1 <atkins JL+ Predic$in) measurement o* $he 'ancreatic duct size 'ancreas divisum "% inspec$ion o* $&e minor 'api##a: a *ollo-ing intravenous administration o* 'rospec$ive s$ud%+ J C#in Gas$roen$ero# 2007; 41:422-7+ + Geman AI1 McDa% LD1 Si#verman PM+ Pancreas secretin. A significant limitation o* $his tes$ is divisum: t&in-sec$ion C:. Radio#o)% 1988; 169:395-8. $hat $he 'ancreas cannot "e reliab#% visualized 8. Man*redi A1 !os$amagna K1 @rizi MK. Severe c&ronic in all 'atients "ecause o* "od% habitus1 'ancreati$is versus suspec$ed 'ancreatic disease: d%namic MA c&o#an)io'ancreato)rap&% af$er secre$in s$imu#ation+ overlap'ing "o-e# )as1 or 'ain+ A#$hou)& Aadio#o)% 2000; 214:849-55. secretin-stimulated H= in 'ancreas divisum 9. @re$ PM1 Aein&o#d !1 :aoure# P+ Pancreas divisum: evaluation -i$& MA c&o#an)io'ancreato)rap&%+ Aadio#o)% ma% no$ demonstrate $he anomalous ductal 1996; 199:99-103. anatom%1 it ma% 'rovide evidence o* stenosis 10. <ars&a- AL1 Simeone JF1 Sc&apiro A>1 F#avin- in 'atients -it& acute recurrent 'ancreatitis <arsha- @+ Cvaluation and $reatmen$ o* $&e dominan$ dorsal duc$ syndrome ('ancreas divisum rede6ned)+ Am J or chronic 'ancreatitis and 'redict -hich Sur) 1990; 159:59-7;+ 'atients ma% res'ond $o sur)ical or endosco'ic $herap%+ 131.
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