Pancreas Divisum is a common congenital malformation of the pancreas, occurring in approximately 4% of the population.^1-3 Divisum is caused by the embryologic failure of the dorsal and ventral pancreatic ducts to fuse, and results in the main pancreatic drainage to go through a relatively narrow minor duct. Figure 1 is a Visible Human model showing divisum. As seen in the image, the dorsal duct and ventral (major) duct are not connected. A link to the Visible Human is provided which allows the reader to examine the models and the associated anatomy. (Figure 2)

This issue features a review on pancreas divisum by Drs Nalini Guda and Martin Freeman which provides the perspective of physicians with expertise in the diagnosis and management of patients with this condition

The diagnosis is best established by ERCP, but EUS can sometimes identify patients with divisum^4,5, as can MRCP⁶. Video 1 is a radial array EUS movie showing a patient with divisum.

Figure 1	Figure 2 Click here to launch Interactive Atlas	Larger Versions Low Resolution (551 KB) High Resolution (2.5 MB)

It has been a bit controversial to define how pathologic divisum actually is.^2,3 As mentioned, it is common, and usually asymptomatic. For example, the Visible Human Male data set was derived from an individual with pancreas divisum.

However, it is also known that people with pancreatitis have a greater chance of having divisum than would be expected if divisum was unrelated to pancreatic disease. In one series, 25% of people with unexplained pancreatitis had divisum. It is hypothesized that divisum causes a relative obstruction to pancreatic flow, and an increased risk of pancreatitis.

The review by Dr’s Guda and Freeman will hopefully help physicians gain a better understanding of pancreas divisum and provide a diagnostic–therapeutic strategy which the readers can employ.

References

1. Cotton PB. Congenital anomaly of pancreas divisum as cause of obstructive pain and pancreatitis. Gut. 1980 Feb;21(2):105-14 <Related link>

2. Warshaw AL, Simeone JF, Schapiro RH, Flavin-Warshaw B. Evaluation and treatment of the dominant dorsal duct syndrome (pancreas divisum redefined). Am J Surg. 1990 Jan;159(1):59-64 <Related link>

3. Dumont F, Yzet T Vibert E, Poirier J, Bartoli E, Delcenserie R, Manaouil D, Dupas JL, Bounicaud D, Regimbeau JM. Pancreas divisum and the dominant dorsal duct syndrome. Ann Chir. 2005 Jan;130(1):5-14 <Related link>

4. Bhutani MS, Hoffman BJ, Hawes RH. Diagnosis of pancreas divisum by endoscopic ultrasonography. Endoscopy. 1999 Feb;31(2):167-9 <Related link>

5. Lai R, Freeman ML, Cass OW, Mallery S. Accurate diagnosis of pancreas divisum by linear-array endoscopic ultrasonography. Endoscopy. 2004 Aug;36(8):705-9 <Related link>

6. Manfredi R, Costamagna G, Brizi MG, Spina S, Maresca G, Vecchioli A, Mutignani M, Marano P. Pancreas divisum: evaluation with secretin-enhanced magnetic resonance cholangiopancreatography.Gastrointest Endosc. 2001 Jun;53(7):728-33<Related link>