Vol.2, No.12, 1401-1404 (2010) Health
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
Research advance in the diagnosis of pancreas divisum
Zongfu Zheng1, Qicai Liu2,3*
1Department of Laboratory Medicine, the 476 Hospital, Fuzhou, China;
2Department of Laboratory Medicine, the first Affiliated Hospital, Fujian Medical University, Fuzhou, China;
3Department of Gene Dignosis, Fujian Medical University, Fuzhou, China;
*Corresponding Author: lqc673@yahoo.com.cn
Received 10 August 2010; revised 24 August 2010; accepted 2 September 2010
Pancreas divisum is a kind of congenital ana-
tomic abnormality; its diagnostic basis depends
mainly on imaging examination. With the de-
velopment of medical science, imaging tech-
nology has been improved and added, and a
complete examination system including ERCP,
B-Ultrasound, MRCP, S-MRCP and CT, etc. has
been formed. Ther e are even researcher, through
further analysis of pancreas divisum on the lev-
el of genes, found that CFTR is a risk factor
causing such disease. This paper is focused on
the value of these examination methods in the
diagnosis of pancreas divisum.
Keywords: Pancreas Divisum; Endoscopic
Retrograde Cholangiopa ncreatog raphy (EPCR);
Magnetic Resonance Ch olangiopancreatography
(MRCP); Computed Tomography (CT); Cystic
Fibrosis Transmem brane Conductance Regulator
Pancreas divisum originally referred to the do uble-pan
creas formed as the dorsal pancreas cannot be fused with
the ventral pancreas, a rare congenital malformation.
While in nowadays its definition is broadened to be a
kind of congenital dysplasia, the most common conge-
nital variation in the development process of pancreatic
duct, and usually refers to the infusion of ventral pan-
creatic duct and dorsal pancreatic duct in the process of
development [1]. Initially, researchers found that the
probability of PD among idiopathic pancreatitis patients
is higher. Cotton [2] once reported that it is found that
there were 3.6% of 169 patients who took pan creatogra-
phy examination because of biliary tract diseases have
got pancreas divisum; in addition, there is 25.6% of idi-
opathic pancreatitis patients have got pancreas divisum
found through pancreatography examination [3]. And
someone thought that PD may occur at any age and the
incidence of PD among crowds is at a rate of about 10%
[4]. The clinical manifestations of PD, a congenital ana-
tomic abnormality, include non-symptom, relapsing
pancreatitis, chronic pancreatitis and severe acute pan-
creatitis, and its diagnostic methods rely mainly on the
imaging examination technologies such as ERCP, B-
Ultrasound, MRCP, S-MRCP and CT, etc. Through re-
search on the level of genes, it is found that CFTR is a
risk factor causing PD. This paper will discuss the re-
search progress of these diagnostic methods of PD.
Although PD has been recognized by anatomist a
few hundred years ago, it was not until 1970, with the
emergence of ERCP, there were some researchers
proposed that pancreas divisum and pancreatitis are
associated with each other. People often think that rel-
atively narrow occurs as PD patiets draining pancreatic
juice through dorsal pancreatic duct and minor papilla,
and thus led to the occurrence of pancreatitis. Until
now, however, the relationship between pancreas divi-
sum and pancreatic diseases is not yet clear. The inci-
dence of pancreatic diseases among pancreas di-
visum patients does not has a significant increase
compared with that of normal people. However, stu-
dies show that a large number of pancreas divisum
patients can indeed progressed to pancreatic diseases.
As a resul t, the clin ical v alu e of th is link is p art icular ly
important. Endoscopic retrograde cholangiopancreato-
graphy (EPCR) can provide clear and direct image of
pancreatic duct; and with a higher rate of correct di-
agnosis of lesions in biliary cavity and wall, it can
Z. F. Zheng et al. / Health 2 (2010) 1401-1404
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
clearly display the size, number, narrow scope and
position of the lesions. And for papilla lesion, it can
carry out biopsy, this technology is one of the main
means of diagnosing pancreas and bile duct disease at
present. EPCR presents a significant role in the diag-
nosis of PD [6-10]. Freeman ML, Nelson DB [11], and
some others believe that the uppermost danger of
ERCP is the complications of acute pancreatitis, the
incidence of which is up to 20% among SOD patients
and also 5%-6% among general population. For this
reason, in the past 10 years, ERCP is replaced by en-
doscopic ultrasound (EUS) in diagnosing biliary cal-
culi, tumor, pancreas divisum and pancreatic cyst. As
EUS is characterized by high accuracy and high secu-
rity [12-15], and the same, it also has limitations as
can not make clear diagnosis of SOD (Sphincter of
Oddi Dysfunction). The research of Coyle et al [16]
shows while take the diagnostic application of ERCP
in SOM (sphincter of Oddi manometry) and bile anal-
ysis, there are 80% of the patient can be diagnosed, of
which 20% are diagnosed as PD; in comparation, EUS
is quite useful in diagnosing biliary diseases and mon-
itoring tumors, it can diagnose that there are 9 cases of
patients suffering from chronic pancreatitis while
ERCP cannot do. But EUS cannot diagnose any pa-
tients w ith SOD. Co mpared with EUS, one of th e main
advantages of ERCP is its ablility to monitor and show
the pressure, and once required interventional therapy
can be taken to make diagnosis and treatment, without
the need for such traumatic diagnosis means as
sphincterotomy [17]. Napoleon [18] and some others
think that EUS diagnosis can be made to replace ERCP
in diagnosis of common bile duct stones.
MRCP is an up-to-date technology for th e observation
of the systematic anatomy and pathology forms of pan-
creatic duct. The anatomy and lesions of pancreaticobi-
liary duct system could be shown perfectly in physical
circumstances with it. MRCP is safe, non invasive, has
got no contraindications and complications. In the experi-
ment on assessing outflow obstruction in pancreatic duct
with primary acute recurrent pancreatitis, Khalid et al
[19] apply MRCP of pancreatic exocrine response to
secretin to 10 p atients with primary acute recurrent pan-
creatitis, followed by EPCR, divided into two groups of
with manometry and without manometry. The MRCP
finding pancreatic exocrine response to secretin can pro-
vide high-quality imaging and be able to make diagnosis
of high specificity to pancreatic duct obstruction by us-
ing pressure gauge measurement standard and clinical
standard. All these illustrate the advantag es of MRCP in
observing pancreatic duct abnormality and diagnosing
PD. The coincide rate of ERCP and MRCP is 83%-100%
for lumen expansion, 70%-92% for lumen stenosis and
is 92%-100% for filling defect [20]. In evaluation of the
common diseases of the pancreas, MRCP is a non-
traumatic substitute method for ERCP, and can make
sure that there is no complication in the anatomical
structure of the lumen. For the determination of co mmon
anatomic variation, conditions of pancreatic duct with
pancreatitis, MRCP is quite valuable, especially com-
bined with MRI imaging. However, MRCP has its limi-
tations: 1) all patients not suitable for MRI (such as the
patients wear cardiac pacemakers) are not suitable for
applying MRCP; 2) severe bile-pancreas duct stenosis
often manifested as the signal interruption of certain
section, it cannot find the lesions accomponied with ste-
nosis; 3) the images after reconstructed with maximum
intensity projection reconstruction technology is easy to
cover up minimal lesions. Ueno, etc. [21] also have re-
ported the MRCP’s difficulty in displaying short, thin
ventral pancreatic duct while it is relatively easy to show
thicker ventral pancreatic with a length over 2.8 cm. In
recent years, the researchers also suggested that secre-
tin-enhanced dynamic CPCR (S-MRCP) can clearly sh ow
the infused dorsal and ventral pancreatic ducts of PD
patients, and so as to enhance the image quality of the
pancreatic duct, reduce the false negative rate in MRCP
diagnosis, as well as improve the detection rate [22-26].
Secretin-enhanced ultrasound examination is also a
non-invasive examination method, which could get con-
secutive ultrasonic images of pancreatic duct. But due to
the limitation of the patiets’ somatotype and the gas in-
side the site, it cannot show very clearly anatomy ab-
normality of pancreas divisum.
Computed tomography (CT) is usually used to ana-
lyze the pancreas size, outline and focal lesions of pa-
tients with chronic pancreatitis or chronic abdominal
pain. It is much more difficult for CT to show pancreatic
duct structures than showing substantial pancreatic
structure. By using three-dimensional reconstruction thin
-slice spiral CT can get 3-D images of high quality, the
diagnostic criteria of which is the infuse of the dorsal
and ventral pancreatic duct and the direct connection of
dorsal pancreatic duct and common bile duct. As con-
ventional CT cannot display the duct system of the entire
pancreas, conventional CT has little action in diagnosis
of PD [27]. It is feasible for the multi-detect row com-
puted tomography (MDCT) to take assessment of PD
Z. F. Zheng et al. / Health 2 (2010) 1401-1404
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
when the pancreatic duct can be seen clearly. With
MDCT, Soto JA, Lucey et al [28] found 10 PD patients
among 73 patients with pancreatic diseases, in compari-
son, there are 9 PD patients found with ERCP. In addi-
tion, there is 1 false positive case included in experi-
mental group 1 with MDCT while there are 2 in group 2.
Therefore, experimental group 1 shows that in the diag-
nosis of PD, MDCT’s sen sitive rate is 95% and its speci-
ficity is 95%; experimental group 2 shows that in the
diagnosis of PD, MDCT’s sensitive rate is 95% and its
specificity is 97%. Therefo re, MDCT is very valuable in
the diagnosis of PD, subject to the pancreatic duct is
clearly visible.
Dray X [29] and someone else studied the relationship
between Cystic Fibrosis Transmembrane Conductance
Regulator (CFTR) and recurrent pancreatitis caused by
pancreas divisum. Their results suggest that even mild
decline of CFTR function can lead to significant changes
in pancreatic exocrine function, that is, to arise the in-
creases of the viscosity of exocrine of pancreas and the
formation of protein precipitation through the secretion
of images chloride and bicarbonate, and the function
decrease of this gene may also result in excessive in-
flammatory response and thus causing local tissue ade-
ma. Taken together, CFTR dysfunction leads to the oc-
currence of pancreatitis through the duct and inflamma-
tory edema caused by. They also pointed out that the
occurrence of pancreatitis caused directly by itself is
accidental, but when combined with CFTR dysfunction,
pancreas divisum becomes an important factor causing
pancreatitis. CFTR dysfunction itself is not an important
factor for the onset of pancreatitis, but when combined
with modifier gene abnormality, alcohol consumption or
and other congenital anomalies, it may cause pancreatitis.
It is very important to know pancreas divisum, a kind of
congenital abnormality, since its existing ratio is rela-
tively high among the popu lation. Although the possibil-
ity of pancreatic diseases being caused directly by CFTR
itself is low, the CFTR abnormality could serve as a
foundation for pancreatic diseases. The abnormality of
CFTR often leads to pancreatitis increasing the density
of pancreatin, which in turn gives rise to or be accompa-
nied by local inflammation, making the accessory nipple
narrow, and finally results in total and relative blockage
of major drainage pancreatic ducts, and thus brings
about pancreatic disease symptoms, namely pancreas
divisum [29]. In other words, CFTR is a dangerous fac-
tor contributing to pancreas divisum, so it can be used as
an auxiliary diagnosis standard for assessing the pan-
creas divisum.
Pancreas divisum, the most common congenital muta-
tion in the development of pancreatic duct, was not rec-
ognised until the 1970s when EPCR was invented and
applied. EPCR is the golden criteria for diagnosing pan-
creas divisum, and also a main treatment for it. In recent
years, the rapid development of the photography tech-
nology has improved the role of technologies such as
Ultrasound, Thin-slice CT, MDCT, MRCP in diagnosing
pancreas divisum. Especially, the present S-MRCP with
noninvasive and highspecific characteristics is the most
promising diagnostic means [30]. The above-mentioned
dianostic means have their own limitations in clinical
application. The gene diagnosis also supplies the patients
suffering pancreas divisum with another choice. And as
an alterative method in diagnosis and research, it leads
us to an in-depth understanding of pancreas divisum at
molecular level.
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