A case of pancreas divisum accompanied by acute pancreatitis and pancreatic pseudocyst

An 82-year-old female was admitted to our hospital with acute pancreatitis in November 2011 and March 2012. Soon after discharge she presented with jaundice. Hematological examination on admission revealed an increase of total bilirubin (5.8mg/dl) with direct dominant (4.2mg/dl) and S-amylase (207IU/l), WBC (7,000/μl), CRP (3.7mg/dl) as well as hepato-biliary enzyme elevation (AST 123IU/l, ALT 102IU/l, ALP 1,026IU/l, γGTP 193IU/l). Computed tomography (CT) revealed a pseudocyst (8.5cm) at the head of the pancreas. After percutaneous transhepatic gallbladder drainage (PTGBD), we performed pancreatic cyst drainage under EUS and placed a 7-Fr 4-cm pigtail catheter with external fistula and a catheter with external fistula. Follow-up CT two weeks later showed diminution of the cyst. Magnetic resonance cholangiopancreatography (MRCP) findings at the previous admission were compatible with pancreas divism. Pancreatic cystography from the external fistula showed that the cyst communicated with the dorsal pancreatic duct. Increased resistance to flow across the small orifice of minor duodenal papilla caused dorsal pancreatic duct hypertension, resulting in acute recurrent pancreatitis and pancreatic pseudocyst. Endoscopic retrograde cholangiopancreatography (ERCP) from the minor duodenal papilla showed the dorsal pancreatic duct, but ERCP from Vater’s papilla did not. After endoscopic sphincterotomy of the minor papilla, we placed a 7-Fr 6-cm plastic stent at the dorsal pancreatic duct. The plastic stent was removed 2 months later. The patient is under observation with no current signs of recurrence.