Symptomatic Pancreas Divisum: Recurrent Acute Pancreatitis in a 23-Year-Old Man

Interventional therapy in patients with symptomatic pancreas divisum is aimed at mitigating the progression to chronic pancreatitis. There are 2 types of chronic pancreatitis: chronic relapsing pancreatitis, and established chronic pancreatitis. Chronic relapsing pancreatitis is typified by attacks in patients who do not yet have clinically recognized hallmarks of chronic pancreatitis but who have the pathology of chronic pancreatitis. Established chronic pancreatitis has the clinically recognized hallmarks of chronic pancreatitis with or without relapsing attacks of pain.⁷ The hallmarks of chronic pancreatitis are repeated attacks of pancreatitis, with eventual destruction of acinar and islet cells progressing to where the acinar cells are too few to evaluate, and enzyme levels decrease leading to steatorrhea, creatorrhea, glycosuria, and hyperglycemia.¹⁶ Chronic relapsing pancreatitis was first described in 1946 by Comfort and colleagues, mainly in alcoholic pancreatitis as relapsing pain in the presence of ongoing disease.¹⁶

Later, Ammann and colleagues stated that pain quality can distinguish early and late pancreatitis.¹⁷ Episodes of relapsing pain characterize the early stage of alcoholic pancreatitis; chronic pain is associated with local complications such as pseudocysts and cholestasis, while complete pain relief occurs in advanced chronic pancreatitis.⁷ Recurrent acute pancreatitis presents similarly to chronic relapsing pancreatitis; however, DiMagno and DiMagno argue the diagnosis of recurrent acute pancreatitis should be reserved for identifiable causes of acute pancreatitis that do not lead to chronic pancreatitis if the causes (gallstones, hypertriglyceridemia) are treated.⁷

Patients with chronic pain between episodes may have no evidence of chronic pancreatitis even using the most sensitive tests. Categorization of patients into those with recurrent acute pancreatitis, chronic pancreatitis, and chronic abdominal pain may be artificial.¹⁸ The classification of symptomatic pancreas divisum remains controversial, although some studies have associated different outcomes regarding improvement of symptoms based on whether the patient demonstrated recurrent acute pancreatitis, chronic pancreatitis, or chronic abdominal pain.

The role of pancreas divisum in recurrent acute pancreatitis is supported by the fact that minor papilla endotherapy has been followed by clinical improvement in those patients. Gupta and colleagues found pancreas divisum in 10% of patients undergoing MRCP for recurrent acute pancreatitis, which was significantly higher than the frequency of pancreas divisum in patients without any pancreatic disease.¹⁹ Patients with chronic pancreatitis demonstrated a similar prevalence of pancreas divisum to those without pancreatic disease. This seems to indicate an association with the development of recurrent acute pancreatitis and pancreas divisum, but this association may not exist between the development of chronic pancreatitis and pancreas divisum. Minor papilla endotherapy is recognized as an effective method for alleviating pain, narcotic use, and readmissions because of recurrent acute pancreatitis and chronic pancreatitis in the setting of pancreas divisum.²⁰