Pancreatic Divisum And Ductal Anomalies

Pancreatic Divisum And Ductal Anomalies

Pancreatic divisum is the most common congenital abnormality of the pancreas. It is found in 5-10% of patients. It is caused by failure of fusion of the dorsal and ventral portions of the developing pancreas. In the majority of patients, this anomaly is of no clinical importance.

In a certain subset of patients, however, estimated to be approximately 5-20%, pancreatic divisum is a clinically important cause of abdominal pain, acute recurrent pancreatitis or chronic pancreatitis. The frequency of pancreatic divisum in patients with pancreatitis in recent studies is approximately 10%.

Pancreatic Divisum

• It is one of the uncommon causes of acute pancreatitis.
• In 10% of patients. Majority of pancreas drains through duct of Santorini through lesser papilla.
• Outflow obstruction—treated by sphincteroplasty of minor papilla.

Pathophysiological Consequences

The cause of pancreatitis in this common anomaly is hypothesised to be caused by minor papillary insufficiency caused by papillary fibrosis and subsequent stenosis.

Pancreatic Divisum Diagnosis

• The diagnosis is established by ERCP.
• MRCP is a noninvasive and accurate method of estab-lishing the diagnosis. However, a negative MRCP does not exclude the diagnosis of divisum as the concor-dance with ERCP ranges from 50% to more than 70%.
• The accuracy of the MRCP may be improved by administration of secretin.

Pancreatic Divisum Treatment

• In patients with minimal symptoms, treatment with pancreatic enzymes may reduce pancreatic secretion and hence, pain. Pain management referral may be necessary.
• Patients with acute pancreatitis are estimated to benefit from either surgical minor sphincteroplasty or endoscopic minor papillotomy.

A few anomalies of pancreatic duct are given below.

• Normal anatomy
• Terminal end of accessory duct fibrosed
• Blind ending of accessory duct
• Absent accessory duct
• Blind end of accessory duct with main duct communication.

Pancreatic Fistula Miscellaneous

Pancreatic Fistula: Most common after pancreatic trauma.

Pancreatic Fistula Causes

1. External fistulae occur due to operative injury to the pancreas or due to a pancreatic anastomotic leak.
   • Injury to the tail of pancreas during splenectomy or adrenalectomy.
   • Injury to the head and body during radical gastrec-tomy.
   • Pancreaticojejunostomy for chronic pancreatitis or following Whipple’s operation can also give rise to fistula in the postoperative period.
   • External drainage of an infected pseudocyst.
2. Internal fistulae: It can occur following a blunt injury abdomen wherein the neck of the pancreas is crushed against lumbar spine resulting in injury. Internal fistulae can communicate with pleural space resulting in a pancreaticopleural fistula.

Pancreatic Fistula Clinical Presentation

• In many cases, the patients present with a discharge of straw-coloured fluid from the drain site in the postoperative period.
• Internal fistula can manifest in a totally unexpected manner, sometimes, as a case of pleural effusion.

Pancreatic Fistula Investigations

• Amylase levels in the pleural fluid, peritoneal fluid and in the discharge will be high.
• Abdominal ultrasound is done to rule out a pseudo¬cyst of the pancreas.
• ERCP: It can demonstrate leakage of the dye from the pancreatic duct into the surrounding area or along the fistulous tract and proximal obstruction, if any.
• CT fistulogram can define the exact site of communication to pancreas. It can define the length of the fistula also.
• CT angiogram is indicated in cases of bleeding associated with pancreatic fistula.

Pancreatic Fistula Treatment

1. Conservative treatment
   • In majority of the cases following surgery, the fistulous discharge stops within one to three weeks of time. During this period, the skin is protected by application of zinc oxide cream. Electrolytes have to be checked frequently.
   • Injection octreotide in the dose of 50-100 mg, 8th hourly will help in decreasing fistula output by more than 80-90%.
2. Stenting: Endoscopy, ERCP followed by stenting can be tried, if successful, often fistula will heal. It is very useful in blunt abdominal trauma and pancreatic ductal disruption.
3. Surgical treatment
   • If the fistula persists in spite of conservative treat-ment, fistulectomy with removal of involved part of the pancreas and body or tail has to be done.
   • In very difficult cases (plastered abdomen) or in fistulas on the anterior abdominal side, fistulo- gastrostomy can also be done.
   • Pancreaticojejunostomy is another option.

Complications of Pancreatic Fistula

1. Secondary infection
2. Massive bleeding: It occurs due to digestion of elastin fibres of blood vessels resulting in pseudoaneurysms. Morbidity is high.
3. Ramification which means branching pattern of the fistula renders the surgery difficult.
4. Bronchopancreatic fistula—difficult to treat.

White Bile

• It is a misnomer
• In long-standing cases of obstruction to the CBD, the bile in the CBD gets absorbed and is replaced by mucus secreted from the CBD.
• It is not white but straw coloured.
• It is not bile but is mucus.

White Bile Significance

• It indicates a long-standing obstruction.
• It has to be relieved as an urgent procedure.
• White bile is seen in:
  • Long-standing stricture of the CBD
  • Due to the stones in CBD
  • Rarely, seen in periampullary carcinoma.

Pancreatic Ascites

Pancreatic Ascites Definition: Accumulation of ‘enzyme rich’ pancreatic exudate in It is a protein-rich, noninfected fluid with protein levels greater than 25 g/L.

Pancreatic Ascites Causes

• Acute pancreatitis mainly alcoholic
• Chronic pancreatitis
• Trauma to pancreas
• Ruptured pseudocyst

Pancreatic Ascites Pathogenesis

• Disruption of ductal system of pancreas followed by spread of enzyme-rich fluid both anteriorly and posteriorly results in pancreatic ascites.
• Anterior rupture results in ascites.
• Posterior spread results in pleural effusion.

Pancreatic Ascites Clinical Features

• History suggestive of pancreatitis, gross abdominal distention.
• Shifting dullness
• Breathlessness—due to pleural effusion.

Pancreatic Ascites Investigations

• Serum amylase, may be elevated due to reab sorption across peritoneal membrane.
• Ultrasound/CT: It can detect fluid, pancreatic duct and guide aspiration.
• ERCP: May slow ductal communication.

Pancreatic Ascites Treatment

• Repeated tapping— follow with albumin infusion. Most of the cases are associated with hypoalbuminaemia
• Octreotide to decrease pancreatic secretion.
• Total parenteral nutrition
• ERCP—pancreatic duct severe hypoalbuminaemia stenting
• Surgical: If there is no response by 2-3 weeks, resection (for tail lesion) or drainage for body lesion is indicated.

Pancreatic Ascites Islet Cell Transplantation: This is emerging as a fine treatment for diabetes and chronic pancreatitis after pancreatectomy. Many patients have undergone islet cell transplantation with minimal complications.