Pancreas divisum: what it is, whether it causes problems and how it is investigated

The NHS describes the pancreas as an organ in the middle of the tummy that helps with digestion and makes hormones such as insulin. Digestive juices from the pancreas drain through a duct system into the first part of the small intestine.

The National Pancreas Foundation explains that the human embryo begins life with two ducts in the pancreas, the ventral duct and the dorsal duct, which normally fuse to form one main pancreatic duct in more than 90% of embryos. In approximately 10% the ducts fail to fuse, resulting in pancreas divisum. In that case most of the pancreas drains through the dorsal duct, which opens into a smaller opening called the minor papilla.

A case report from Italy gives the figure of 5% to 14% of the general population, and describes two forms, a complete form that is most common and an incomplete form in which the two systems remain connected through small branch ducts. The exact figure varies between studies, but all describe it as a relatively common variation rather than a rare disease.

The National Pancreas Foundation says that a majority of individuals born with pancreas divisum will not have symptoms, and that a small group will develop symptoms which commonly include abdominal pain, nausea, vomiting and acute and chronic pancreatitis. It is frequently discovered by chance on a scan done for another reason.

The Canadian review proposes that the usual explanation for problems is that drainage through the small minor papilla can be inadequate, causing pain from obstruction and sometimes pancreatitis. It notes that people whose pancreatitis is a result of pancreas divisum are typically younger, less likely to drink alcohol, more likely to be female and more likely to have a pattern of recurrent acute attacks. It also states that no clear association exists between pancreas divisum and chronic pancreatitis, and that the exact relationship between genetic markers and pancreas divisum is unknown.

Whether pancreas divisum itself causes symptoms in an individual is sometimes debated, which is one reason the diagnosis is made carefully, after the more common causes of pancreatitis such as gallstones and alcohol have been excluded.

The NHS says the main symptom of acute pancreatitis is pain in the tummy, which may start suddenly and not go away, be severe, sharp or knife-like, spread to the back, feel worse after eating and be eased by leaning forward. You may also have a high temperature and feel or be sick. The NHS says to ask for an urgent GP appointment or get help from NHS 111 for sudden severe tummy pain that does not go away or keeps coming back, or with a high temperature or feeling hot, cold or shivery.

It says to call 999 or go to A&E for sudden severe tummy pain with pain spreading to the back, bloating that does not go away, a fast heartbeat or difficulty breathing, or blue or bruised skin around the belly button, waist or upper outer thigh. Acute pancreatitis needs treatment in hospital and can be life-threatening.

The NHS lists the most common causes of acute pancreatitis as gallstones and drinking a lot of alcohol. It lists among the causes of chronic pancreatitis the pancreas not developing properly at birth, a category that includes pancreas divisum.

The Canadian review says that although CT and transabdominal scans are often used for people with pancreatitis, to rule out gallstones and cysts, pancreas divisum is not reliably detected by such scans. In most cases it is best diagnosed by endoscopic retrograde cholangiopancreatography (ERCP), magnetic resonance cholangiopancreatography (MRCP) or endoscopic ultrasound. It notes that MRCP is a non-invasive way to show the duct anatomy, while ERCP both diagnoses and allows treatment but can itself irritate the pancreas and cause pancreatitis.

The National Pancreas Foundation likewise says the most common and accurate way of diagnosing it is by MRCP or ERCP, which can demonstrate two separately draining ducts, and that CT and MRI can assist. The Italian case report advises MRCP for people with recurrent pancreatitis when gallstones and alcohol are absent, as it is the most appropriate non-invasive test of the pancreatic and biliary systems.

In the UK, an investigation like this is typically arranged by a gastroenterologist after repeated unexplained episodes of pancreatitis, rather than for a person without symptoms.

The National Pancreas Foundation says that pancreas divisum in individuals with no symptoms does not require treatment, and that treatment for those with symptoms varies and has not been well established. The Canadian review lists endoscopic options during ERCP, including sphincterotomy, papillary dilatation and stent insertion, and reports that, in a series of 52 patients who had endoscopic sphincterotomy of the minor papilla, symptoms improved more frequently in people with acute recurrent pancreatitis than in those with chronic pancreatitis.

The National Pancreas Foundation notes that surgery, including sphincterotomy and stenting, can itself cause pancreatitis or, in rare cases, kidney failure and death, and that a trial in the United States was examining ERCP in people with recurrent acute pancreatitis who have pancreas divisum. Because evidence is limited, a decision to treat is individual and made with a specialist team.

For most people, living with it means nothing more than knowing the term. The NHS advice for avoiding another episode of acute pancreatitis is to drink less alcohol or none at all, stop smoking and eat a healthy low-fat diet. It says that if you have had acute pancreatitis once, it is possible to get it again.

The NHS says people with chronic pancreatitis should not drink alcohol and should not smoke, because both can speed damage, and that treatment can help manage symptoms and related problems like diabetes or difficulty absorbing nutrients from food. Tell your GP if you have repeated episodes of upper tummy pain, so that the cause can be investigated.

On the NHS, pancreas divisum is looked after by a gastroenterologist or hepatobiliary and pancreatic surgeon, with MRCP or endoscopic ultrasound as the main imaging tests. Procedures such as ERCP are done in endoscopy units with experience in pancreatic disease. A private opinion can shorten waits for imaging, but because the evidence for intervention is limited, it is worth asking how many such procedures a unit performs and what outcomes it expects for your situation.