University of Miami, Jackson Memorial Hospital Atlantis, FL, United States
Larnelle N. Simms, MD1, Laura Suzanne K. Suarez, MD2, Armando Rodriquez, MD3, Jose Proenza, MD4 1University of Miami, Jackson Memorial Hospital, Atlantis, FL; 2University of Miami at JFK Medical Center, Atlantis, FL; 3University of Miami, JFK Medical Center Palm Beach, Atlantis, FL; 4University of Miami, JFK Medical Center Palm Beach, West Palm Beach, FL
Introduction: Pancreas divisum (PD) occurs in up to 10% of the population and is usually asymptomatic. We review the pathophysiology of the development of recurrent pancreatitis and post-ERCP hemorrhage in an elderly man with pancreas divisum.
Case Description/Methods: A 70-year-old man with a six-month history of four episodes of recurrent pancreatitis, presented with two days of worsening abdominal pain, nausea, and vomiting. His evaluation was notable for epigastric tenderness, mildly elevated lipase, and CT findings of acute pancreatitis with a multi-loculated pseudocyst in the region of the tail of the pancreas. ERCP demonstrated a complete pancreas divisum with a dilated common bile duct, mild ductal dilatation, and fistula in the pancreatic body and tail, and distal pancreatic duct stenosis. Sphincterotomy and sphincteroplasty of the minor papilla followed by multiple sweeps and stents deployed into the pancreatic fistula. The next day he experienced sudden abdominal pain, hypotension, and a 4-gram drop of hemoglobin. Repeat imaging demonstrated interval development of splenic subcapsular hematoma with hemoperitoneum. Emergent blood transfusion and splenic artery embolization were performed followed by safe discharge.
Discussion: Pancreas divisum is a congenital anomaly in which the ventral and dorsal parts of the pancreas fail to fuse. This causes the pancreatic body, tail, isthmus, and accessory pancreatic duct to drain separately into the minor papilla instead of the major papilla. The entity of false pancreas divisum is an acquired obstructing lesion resulting from scaring after an acute inflammatory episode of pancreatitis. Accessory papilla sphincteroplasty is effective for true divisum such as this case, whereas false pancreas divisum requires distal pancreatectomy to overcome the main pancreatic duct obstruction. ERCP remains the standard in diagnosing this condition. The percentage of splenic bleeding after ERCP ranges from 1-3%, with less than 30 cases being reported. Causes include direct trauma, bowing of the endoscope along the greater curvature of the stomach, avulsion of short gastric and/or splenic vessels, and splenic capsule laceration during adhesiolysis. Chronic pancreatitis results in fibrosis of the splenocolic and gastric ligaments thus carrying an increased risk of rupture with traction forces during ERCP. As such, hemodynamic instability and an abrupt drop in hemoglobin require immediate action to prevent life-threatening hemorrhage.
Figure: Figure 1A. ERCP demonstrating dilated common bile duct (red arrow) and pancreatic duct (blue arrow). 1B. Computed tomography of the abdomen demonstrating a large splenic subcapsular hematoma.
Larnelle Simms indicated no relevant financial relationships.
Laura Suzanne Suarez indicated no relevant financial relationships.
Armando Rodriquez indicated no relevant financial relationships.
Jose Proenza indicated no relevant financial relationships.
Larnelle N. Simms, MD1, Laura Suzanne K. Suarez, MD2, Armando Rodriquez, MD3, Jose Proenza, MD4. P0083 - Divide and Rupture: Splenic Hemorrhage Post Endoscopic Retrograde Cholangiopancreatography in an Elderly Man With Pancreas Divisum, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.