Chronic Pancreatitis and Pancreas Divisum: A Case Report of Recurrent Management Challenges

Abstract

Pancreas divisum, resulting from incomplete fusion of the pancreatic ducts during development, disrupts normal drainage and can lead to recurrent acute and chronic pancreatitis. This report presents a case of a 46-year-old male with chronic necrotizing pancreatitis secondary to pancreas divisum. The patient experienced multiple hospital admissions and underwent a cholecystectomy before the underlying etiology, pancreas divisum, was identified after six hospitalizations. This case highlights the diagnostic challenges of recurrent pancreatitis, emphasizing the importance of considering congenital pancreatic anomalies in patients with unexplained or refractory disease. It also underscores the need for a systematic approach to evaluating recurrent pancreatitis to avoid delays in diagnosis and unnecessary interventions. Pancreas divisum is associated with recurrent pancreatitis in a subset of patients. While endoscopic retrograde cholangiopancreatography remains the gold standard for diagnosis and intervention, non-invasive imaging such as magnetic resonance cholangiopancreatography is preferred for initial diagnosis. Endoscopic treatment, including minor papilla papillotomy and stenting, is typically effective for symptomatic cases. However, surgery may be necessary when these methods fail.

Keywords: acute-on-chronic pancreatitis; endoscopy ercp; pancreatic divisum; recurrent acute pancreatitis; recurrent pancreatitis.

Figure 1. Computed tomography of the abdomen showing pancreatic ductal dilation prompting an MRCP.

MRCP: magnetic resonance cholangiopancreatography.

Figure 2. MRCP demonstrating pancreas divisum

MRCP (magnetic resonance cholangiopancreatography) coronal MIP (maximum intensity projection) image in a patient with a history of recurrent pancreatitis. There is significant alteration of the baseline variant anatomy due to prior necrotizing pancreatitis, resulting in discontinuity of the main pancreatic duct (MPD) and dilated side branches at the neck of the pancreas. The MPD is noted to insert at the minor papilla, separate from the common bile duct insertion into the major papilla, consistent with pancreatic divisum.