A Fortuitous Diagnosis Of Pancreas Divisum Using Endoscopic Ultrasound Guided Rendezvous Access

Purpose: Pancreas divisum is the most common pancreatic congenital anomaly wherein the smaller ventral ducts drains through the larger major papilla and the larger dorsal duct drains through the smaller minor papilla. It is present in 7% of the general population with 5% develop symptoms. We present a case of unexpected diagnoses of pancreas divisum using endoscopic ultrasound (EUS) guided rendezvous pancreatic duct (PD) access. Methods: A 65-year-old Caucasian lady with history of hypertension and prior cholecystectomy was referred to our institution with a history of four episodes of recurrent acute pancreatitis (AP) over a span of 6 years. Patient underwent multiple CT scans and an MRI of her abdomen which were all reported normal. Initial endoscopic ultrasound (EUS) done about a year ago revealed chronic pancreatitis changes. ERCP with limited sphincterotomy (due to a large periampullary diveritculum) revealed microlithiasis. Results: Despite biliary sphincterotomy, patient developed another episode of AP. Repeat MRI from the referring hospital revealed a diffusely dilated PD (0.5 cm). Repeat ERCP was unsuccessful in PD cannulation. Patient returned for an EUS guided rendezvous PD access. Under EUS guidance, the PD was accessed and a guidewire was passed anterogradely into the duodenal lumen. Surprisingly the guidewire was noted to be coming out of the minor papilla raising suspicion of pancreas divisum. An endoscopic retrograde pancreatogram confirmed the presence of complete pancreatic divisum. Given this finding, minor papillary sphincterotomy with stent placement was performed. Patient thus far has not had further episodes of pancreatitis. Conclusion: Discussion: Pancreas divisum is the most common pancreatic congenital anomaly resulting in recurrent AP. The diagnosis of pancreas divisum is usually made by endoscopic retrograde cholangiopancreatography (ERCP) in patients presenting with pancreatobiliary symptoms. It was significantly more common in patients presenting with idiopathic pancreatitis (up to 50 percent) than in controls or in the general population. This case has multiple interesting points. In the absence of alcohol use and gallstone disease, recurrent AP should raise the suspicion for anatomic variations (mainly pancreas divisum), medications, etc. Diagnosis of pancreas divisum was missed despite multiple imaging studies and finally obtaining pancreatogram via EUS guided rendezvous PD access confirmed the diagnosis.Figure