Introduction: Despite the relative rarity of congenital anomalies of the pancreas, they can result in some clinical symptoms, such as recurrent abdominal pain, recurrent acute pancreatitis (RAP), or chronic pancreatitis. Nearly 8-10% of the population experience pancreatic congenital anomalies. The most common is the pancreas divisum (PD). To successfully treat a symptomatic PD, minor papillotomy (MiP) is the mainstay of endoscopic therapy, especially when access is difficult via the major papilla. Here we present a case of PD complicated with necrotizing pancreatitis successfully treated with MiP and pancreatic stenting.
Case Description/Methods: A 56-year-old female with prior history of recurrent acute pancreatitis (RAP) presented with intermittent epigastric pain, nausea, and vomiting for one month. The patient admitted to the social use of alcohol only and no tobacco use. A physical exam showed stable vital signs and mild epigastric tenderness. Laboratory work showed mild elevation of WBC (12 x 109/L) and serum lipase 5 x of ULN. Liver & kidney functions were within normal limits. Magnetic resonance imaging (MRI) showed multiple pancreatic fluid collections (PFC) (image a) and evidence of incomplete pancreatic divisum (PD). Endosonography showed a large pseudocyst between the liver and stomach and walled-off necrosis around the pancreatic head, invading a thrombosed main portal vein (PV) (Image b). Also, EUS confirmed incomplete PD (image c). Transluminal drainage of the WON was not attempted because of the PV invasion. Endoscopic retrograde cholangiopancreatography (ERCP) was successfully performed, with major & minor pancreatic papillotomy & plastic stenting (image d). Biliary cannulation showed a dilated bile duct but was otherwise unremarkable. The patient was continued on supportive therapy and later required percutaneous drainage of the pseudocyst between the liver and stomach. A subsequent MRI showed significant WON resolution three months later, and the patient was convalescing well.
Discussion: Minor papillotomy (MiP) is the cornerstone of endoscopic therapy for symptomatic PD (RAP, chronic pancreatitis, or chronic abdominal pain). MiP as an adjunct treatment for walled-off necrosis (WON) has not been described in the few studies that assessed endoscopic therapy for symptomatic PD. MiP and endoscopic therapy use in PD with WON might benefit this subset of patients, but that requires further investigation.
