A Less Common Cause of Pancreatitis

Introduction: Pancreas Divisum is the most common congenital variation of pancreatic duct anatomy but is often overlooked as an underlying contributor to acute pancreatitis. Case Description/Methods: A 59yo male without significant past medical history presented to the hospital with 1 day of nausea and 8/10 pain across the entire upper abdomen. Initial laboratory evaluation was significant for mild leukocytosis 12.11 K/uL, elevated lipase greater than 3,000 U/L, and total bilirubin of 1.3 mg/dL. Imaging completed in the emergency room showed normal biliary ducts and mild inflammatory changes surrounding the pancreas as well as second and third portions of the duodenum suggesting mild pancreatitis versus duodenitis. There was also suggestion of some mild dilation of the distal pancreatic duct (PD) within the pancreatic head concerning for distal obstruction. The patient was initially treated supportively including adequate IV fluid resuscitation with lactated Ringer's with persistence of his symptoms prompting further endoscopic evaluation. An endoscopic ultrasound was completed the next morning revealing diffuse pancreatic parenchymal abnormalities including lobularity and hyperechoic stranding as well as a single hyperechoic foci measuring up to 3 mm in diameter in the pancreatic head suggestive of an obstructing pancreatic duct stone. ERCP was then performed, revealing a normal major papilla and normal intra and extrahepatic biliary system. The minor papilla was noted to be congested and edematous and was accessed revealing a distal stone with diffuse upstream dilation of the duct, which was not communicating with the main pancreatic duct, confirming pancreas divisum. Following 6 mm dorsal pancreatic sphincterotomy, the stone was successfully removed with a 9mm balloon and a 5Fr × 3cm PD stent with external pigtail was placed. The patient did very well after the procedure with complete resolution of his presenting symptoms and was discharged 2 days later. He was seen in clinic 6 weeks later where he was noted to be doing well and without complaints and the stent was confirmed to have passed spontaneously. Discussion: This case demonstrates the importance of maintaining a wide differential diagnosis when treating patients for pancreatitis. Although this patient’s congenital abnormality was overlooked on initial imaging, thorough endoscopic investigation with direct visualization of minor papilla swelling was the clue leading to his diagnosis and treatment of pancreas divisum with obstructing duct stone.Figure 1.: Minor papilla with stone being extracted.