S3609 Acute Recurrent Pancreatitis in a Woman With Pancreatic Divisum

Introduction: Pancreatic divisum (PD) is a congenital anomaly resulting from failure of ventral and dorsal pancreatic ducts to fuse, leaving a main pancreatic duct joining the common bile duct (CBD) to drain into the major duodenal papilla and an accessory duct draining into the minor duodenal papilla. While the condition is asymptomatic in 95% of the affected population, it has been reported as a cause of acute recurrent pancreatitis (ARP). Here we examine the case of a patient with acute recurrent pancreatitis of unknown etiology and was found to have PD and impacted accessory duct stones. Case Description/Methods: A 79-year-old woman presented with left upper quadrant and epigastric pain for one day. Past medical history significant for cholecystectomy 24 years ago and acute pancreatitis of unknown etiology 2 years ago. Lipase was normal, but computed tomography demonstrated edema at the pancreatic head and 2 punctate calcifications in the pancreatic duct with ductal dilation. Triglycerides were normal, and there was no history of alcohol use. Magnetic resonance cholangiopancreatography (MRCP) showed PD and a dilated accessory pancreatic duct with 2 separate filling defects. She clinically improved with supportive care and was advised to follow up in the clinic to discuss endoscopic retrograde cholangiopancreatography (ERCP). She returned 1 day after hospital discharge with recurrent abdominal pain. Lipase increased to 1,474, and the decision was made to pursue inpatient endoscopic ultrasound (EUS)/endoscopic retrograde cholangiopancreatography (ERCP). The accessory pancreatic duct was dilated on EUS to 6-7 mm wide, and it appeared to communicate with the main pancreatic duct. There were 2 stones in the accessory pancreatic duct which were removed via ERCP. Retrograde filling of the main pancreatic duct, CBD and common hepatic duct were noted on pancreatogram due to the presence of the accessory duct stones. After a pancreatic sphincterotomy, balloon sweeps of the accessory duct removed medium sized white stones and sludge. Pancreatoscopy confirmed no residual stones. She developed post-ERCP pancreatitis but quickly improved with supportive care and was discharged home. Discussion: While PD is one of the most common congenital anomalies of the pancreas and there is debate of whether it truly causes symptoms, the formation of associated pancreatic duct stones causing ductal obstruction resulting in ARP is uncommon. This case demonstrates successful endoscopic management of a possible complication of PD resulting in ARP. Early endoscopic therapy should be considered as it can decrease readmissions and the potential need for surgical management of ARP.