Diagnosis of Pancreas Divisum Using Linear-Array Endosonography

BackgroundEndoscopic ultrasound (EUS) is an important tool in the evaluation of idiopathic or recurrent acute pancreatitis and prior to high-risk endoscopic retrograde cholangiopancreatography (ERCP), such as ampullectomy and sphincter of Oddi manometry. Linear-array EUS provides detailed imaging of the pancreas in a non-invasive manner and can accurately identify pancreas divisum in most patients.Patient and methodsLinear-array EUS is used to demonstrate the normal pancreatic ductal anatomy. Three clinical cases are then presented to demonstrate the endosonographic findings in pancreas divisum. (1) A 64 year-old female with history of pancreatitis undergoes an MRI, which shows an irregular calcified area in the head/uncinate of the pancreas and pancreas divisum. (2) A 55 year-old female undergoes EUS prior to ERCP for evaluation of sphincter of Oddi dysfunction. Pancreas divisum is noted on EUS and later confirmed with ERCP. (3) A 50 year-old female with abdominal pain undergoes an MRI, which shows a peri-ampullary cystic structure and pancreas divisum.ResultsPancreas divisum can be detected with linear EUS by the inability to follow the main pancreatic duct (PD) from the major ampulla to the body of the pancreas, or from the relatively hypoechoic ventral pancreas to the more echogenic dorsal pancreas. Often in cases of pancreas divisum, the main PD can be seen merging with the duodenal wall at the minor papilla.ConclusionsLinear-array EUS is an effective way to detect pancreas divisum, which is important in the work-up of idiopathic pancreatitis and in defining pancreatic ductal anatomy prior to ERCP.