Department of Surgery Aga Khan University Hospital, Karachi, Pakistan.

Background: One of the uncommon reasons of recurrent pancreatitis is pancreas divisum. A difficult diagnosis can result in recurrent pancreatitis episodes and, ultimately, pancreatic failure.

Case: In this instance, a young woman with a history of recurrent upper abdominal pain attacks is presented.

Diagnosis: Pancreatic duct This patient underwent effective ERCP with a slight papillotomy and afterwards underwent the main papilla is stented. Before authoring this case report, the patient provided written informed consent.

Conclusion:This study emphasises the importance of early illness suspicion in individuals with recurrent idiopathic pancreatitis, by As a final therapy option, minimally invasive treatments (ERCP) are clinically effective.

KEYWORDS: Endoscopic Papillotomy, Recurrent Pancreatitis, Pancreas Divisum

One of the most frequent congenital defects in the hepatobiliary system is pancreas divisum. It varies, but the incidence is between 5% and 14% of the general population [1]. This abnormal opening of the primary pancreatic duct at minor papilla is not enough to completely drain the duct secretions, resulting in stasis of enzymes and premature activation of these enzymes results in recurrent attacks of pancreatitis [2, 3]. The disease is caused by failure of fusion of the two embryonic parts of the pancreas, i.e. non-fusion of dorsal and ventral ducts of the pancreas.

The majority of individuals are asymptomatic, and a diagnosis is only made by chance. Ultrasound of the abdomen is not a particularly effective diagnostic tool.The abdomen's computed tomography (CT) may aid in diagnosis, but cholangiography is the preferred imaging method (ERCP or MRCP). The noninvasive nature of MRCP makes it superior, while ERCP has an edge in both its diagnostic and therapeutic capabilities. Endoscopic sphincterotomy is typically used as a type of nonsurgical treatment.

In this case, a young female patient, 24, had a history of recurrent pancreatitis crises, which a workup revealed was related to pancreatic divisum. She underwent endoscopic sphincterotomy successfully, and the recovery period was painless. Report highlights the necessity for early disease detection suspicion of endoscopic sphincterotomy and its effectiveness for the treating this illness.

Prior to publishing this case report, written informed consent was obtained. Our patient, a 24-year-old woman, complained of rapid onset, acute, ongoing epigastric discomfort for the previous four days when she went to the emergency room. This pain was not radiating, made worse by eating, and could only be managed with opiate medicines. Additionally, the pain was accompanied by non-bilious vomiting. She experienced a similar pain episode approximately a year ago, for which she was hospitalised and treated for acute pancreatitis. She had a history of anorexia, malaise, and acid peptic disease. In the last three years, she had lost 6 kg. She was found to be dehydrated and yellow upon testing. Her blood pressure was afebrile at 117/68 and 96 beats per minute.

The epigastric region was painful upon abdominal examination, but there was no mass or viscera that could be felt. The remainder of the systemic evaluation was uneventful. Her initial laboratory results showed a total bilirubin concentration (TLC) of 10600/mm3, total bilirubin with direct bilirubin concentration (direct bilirubin) of 0.9 mg% (0.0 to 0.4), alanine aminotransferase of 71 IU/l (normal 0-31 IU/l), aspartate aminotransferase of 251 IU/l (normal 0-34 IU/l), alkaline was 167 IU/l (3-60) and serum lipase was 99 IU/l (25-125 IU/l).Surprisingly, an abdominal ultrasonogram (US) showed a hypoechoic solid mass in the pancreas' head, causing atrophy in the organ's body and tail, dilated pancreatic ducts, and a large common bile duct suggestive of a cancerous process. A CT scan of the abdomen was performed to further define this scenario, and the results revealed a hypodense mass involving the pancreas' uncinate process that was atrophying the organ's body and tail without infiltrating nearby organs.The common bile duct and pancreatic duct were clearly visible, however the intrahepatic biliary channels appeared dilated.

ogists because it can be difficult to distinguish between Pancreas Divisum and pancreatic cancer. Finally, Pancreas Divisum was tentatively diagnosed due to persuasive evidence of the opening of a dilated primary pancreatic duct at the minor papilla.

Major pancreatic duct was opening at minor papilla while minor pancreatic duct was opening at major papilla, which was confirmed by ERCP, which was performed as a diagnostic and therapeutic measure (figure 2). Minor papillotomy was performed, and plastic stent was put in major pancreatic duct. The surgery was well tolerated by the patient, and neither an immediate nor a delayed problem was found.

The patient recovered quickly following the treatment, and both his appetite and abdominal pain were improved. On the third day after the treatment, she was released. Six months after her last visit to the clinic, she is still pain-free and living a normal, healthy life.

A congenital anatomical defect known as pancreatic divisum is characterised by the failure of the ventral and dorsal halves of the pancreas to fuse during the eighth week of foetal development. Between 5% and 14% of the general population suffer from this disorder [1]. In a large retrospective research from India, patients with pancreatitis were more likely to have a pancreas divisum than those who had biliary disorders or vague abdominal pain (9 versus 2 percent).

The major pancreatic duct, also known as Wirsung's duct, drains the exocrine pancreas' secretions from its head, body, and tail and terminates at the major duodenal papilla (hepatopancreatic ampulla); the accessory pancreatic duct, also known as Santori's duct, runs through the head of the pancreas, crosses Wirsung's duct, and terminates at the minor duoden The minor papilla and major duodenal papilla are separated by about 10 to 15 mm on the medial wall of the second section of the duodenum, respectively, and are exits.

In Pancreatic Divisum, the dorsal pancreatic area channels into the minor duodenal papilla through the major pancreatic pipe; the ventral pancreatic conduit, the more modest piece of the pancreas, converges with the normal bile channel at the hepatopancreatic ampulla. There are two kinds of Pancreatic Divisum: complete(generally normal) and fragmented (considerably less normal), in which the ventral and dorsal frameworks stay associated through smallcaliber branch channels. Roughly 15% of instances of pancreas divisum are of the deficient kind. Be that as it may, the clinical ramifications of deficient pancreas divisum are equivalent to for

exemplary (or complete) pancreas divisum,In PD, the expanded frequency of intense and constant pancreatitis is brought about by deficient seepage of emissions delivered by the body, tail and part of the pancreatic head through an opening which is too little [4, 5]. There is a gathering of patients with pancreas divisum who are dependent upon repetitive episodes of apparently idiopathic pancreatitis [6]. In these patients, the minor papilla hole is little to such an extent that unreasonably high intrapancreatic dorsal ductal pressure happens during dynamic discharge, which might result in lacking seepage, ductal distension, torment, and, in some

cases, pancreatitis. Albeit commonly, patients with pancreas divisum remain clinically asymptomatic, other normal structures of clinical introductions range from intermittent assaults of changing level of pancreatitis, entrail deterrent, ascites, jaundice,shock and in its most extreme structure, can prompt shock. Liquor is by all accounts the setting off factor for the assault of pancreatitis [6]. Our patient gave upper stomach torment auxiliary to pancreatitis.

Symptomatic workup ranges for research center tests to imaging modalities. Research facility workup may show raised amylase or lipase levels showing an episode of pancreatitis, yet they are not exact for diagnosing Pancreas Divisum. Imaging modalities which might assist in analysis with including ultrasound, CT filter midsection however conclusive finding is made with some type of

cholangiography either ERCP or MRCP. PD is the greater part of the times analyzed from MRCP yet the significant highlight note here is that as of now utilized 64 slicer CT filter is a decent methodology to analyze PD like for our situation, particularly when the determination isn't being thought [7]. The standard restorative answer for suggestive Pancreatic Divisum is a sphincterotomy of the minor duodenal papilla, which decongests Wirsung's pipe [8, 9]. Clinical improvement with such treatment has been seen in up to 75 percent of patients. Once in a long while, in chose cases just, is careful treatment demonstrated: careful sphincterotomy, depleting or even fractional pancreatectomies and their outcomes are equivalent with those accomplished by endoscopic methodology [6].

1. Liao Z, Gao R, Wang W, et al. A systematic review on endoscopic detection rate, endotherapy, and surgery for pancreas divisum. Endoscopy 2009;41:439-44.

2. Vasile D, Grigoriu M, Turcu F, et al. [Pancreas divisumea rare cause of chronic pancreatitis]. Chirurgia (Bucur) 2007;102:83-7.

3. Gonoi W, Akai H, Hagiwara K, et al. Pancreas divisum as a predisposing factor for chronic and recurrent idiopathic pancreatitis: initial in vivo survey. Gut (2011);doi:10.1136/gut.2010.230011.

4. Kamisawa T, Tu Y, Egawa N, et al. Clinical implications of incomplete pancreas divisum. JOP 2006; 7:625-30.

5. Ng WK, Tarabain O. Pancreas divisum: a cause of idiopathic acute pancreatitis. CMAJ 2009; 180:949-51.

6. Elena G, Dorin A, Roxana B, Gheorghe B. Pancreas divisum pancreatitis: a case report. Abdom Imaging (2011)36:215–217.

7. Kamisawa T, T. Y. (2007). MRCP of congenital pancreaticobiliary malformation. Abdom Imaging, 129-133.

8. GA, L. (2003). Acute recurrent pancreatitis. Can J Gastroenterol, 381-383.

9. Kamisawa T (2004) Clinical significance of the minor duodenal papilla and accessory pancreatic duct. J Gastroenterol 39:605–615.

Sultan Rizwan. Cause of Recurrent Pancreatitis: Pancreas Divisum. Insights of Clinical and Medical Images 2022.