AUGUST 30, 2000

History: A full day of right upper quadrant pain in an otherwise healthy woman.
CT was performed and selected images are shown.

What is the MOST accurate observation regarding the images above? Pick one answer.
A Gallbladder is abnormal.
B Gallbladder and liver are abnormal.
C Gallbladder and pancreas are abnormal.
D Gallbladder, pancreas and liver are abnormal.
E Gallbladder, pancreas, liver and stomach are abnormal.

Findings: The main pancreatic duct (Wirsung) crosses anterior to the common bile duct and
empties into the duodenum directly instead of emptying into the major papilla. Also noted is
hazy fluid density and fluid around the gallbladder as well as stones within the gallbladder
itself, consistent with acute cholecystitis.

Diagnosis: Pancreas Divisum. Acute cholecystitis

Answer EACH of the following with TRUE or FALSE.

T or F The duct of Wirsung is identified as the pancreatic duct that empties into the major
papilla.
T or F Pancreas divisum can be a cause of acute cholecystitis.
T or F Pancreas divisum is the most common anatomic variant of the pancreas.

Pancreas Divisum
Pancreas divisum is the most common anatomic variant of the pancreas, occurring in 3-7% of
the normal population. Normally, as the duodenum rotates to the right and becomes C-
shaped, the ventral and dorsal buds of the pancreas combine in approximately the 8th week of
fetal life. The main pancreatic duct normally forms from the fusion of the ventral and dorsal
ducts. Pancreas divisum occurs when there is non-union of the ductal systems. The main
pancreatic drainage occurs through the minor papilla, directly into the duodenum.

The clinical significance of pancreas divisum is a contested issue. It has been associated with
non-alcoholic recurrent pancreatitis. Theoretically, the minor papilla is too narrow to permit
free flow of pancreatic secretions, leading to obstruction and pancreatitis. Up to 26% of
patients with nonalcoholic recurrent pancreatitis have pancreas divisum, although not all
authors agree on a causal relationship between the congenital abnormality and idiopathic
pancreatitis. Conservative therapy is usually indicated, but papillotomy and stenting may be
performed if conservative measures fail.

Radiology:

With the advent of 5 mm and 3 mm CT collimation, pancreatic duct structures are more
frequently being identified. The main pancreatic duct normally has its outlet in the region of
the major papilla, where it joins with the common bile duct. Pancreas divisum may be
diagnosed when the main pancreatic duct is visualized entering the duodenum directly
bypassing the common bile duct. An indirect sign is an oblique fat cleft between the uncinate
process and the remaining pancreas, signifying non-union of the ventral and dorsal
embryologic components. Pancreatography may be performed to confirm the diagnosis,
either non-invasively with MRCP or directly with endoscopic retrograde
cholangiopancreatography.

Pearls:

1. Pancreas divisum is the most common anatomic variant of the pancreas, resulting from a
failure of the dorsal and ventral ductal systems to fuse.

2. Divisum may be diagnosed by CT or MR when the main pancreatic duct is seen emptying
directly into the duodenum in the location of the minor papilla rather than at the major papilla
with the common bile duct.

3. An association with nonalcoholic recurrent pancreatitis exists, although a causal relationship

is still debated.

References:

[1] Carr-Locke DL. Pancreas divisum: The controversy goes on. Endoscopy 1991;23:88.
[2] Dahnert W. Radiology Review Manual, 4th ed. pp. 599, Baltimore, Williams & Wilkins,
1999.