Alimentary tract and pancreas

Alimentarni trakt i pankreas

Vojislav N. Peri{i},

Mira Petrovi},

Dragana @ivanovi}

University Childrení Hospital, Belgrade, Serbia.

ARCH GASTROENTEROHEPATOL 2003; 22 (No 1 - 2): 12 – 17

Case report

Duplex ventral pancreas:

another cause of

pancreatitis in children

Prikaz slu~aja

Dvostruki vetralni pankreas: jo{ jedan uzrok

pankreatitisa u dece

(accepted April 4th, 2003)

Key Words:

ventral pancreas, duplication, pancreatitis,

child.

Abstract

Duplication of the ventral pancreatic ductal system was diagnosed in 4.5-year old boy during his

evaluation for recurrent attacks of pancreatitis. Endoscopic retrograde cholangiopancreatography

demonstrated typical changes of chronic pancreatitis confined to one ductal system, with the other

ductal system was completely normal. Both ductal system opacified via commmon opening at the

vestibulum of the major papilla. A minor papilla was present. This rare anomaly of the ventral pancreas

may be another developmental cause of pancreatitis in children.

Sa`etak

Dvostruki duktalni sistem ventralnog pankreasa je utvrdjen u 4.5-godinjeg deaka tokom ispitivanja

etiologije ponavljanih napada akutnog pankreatitisa. Endoskopska retrogradna holangiopankreatografija

je pokazala tipine promene za hronini pankreatitis ograniene na jedan duktalni

sistem, dok je drugi duktalni sistem bio potpuno normalan. Papila minor je bila prisutna. Ova retka

anomalija mo`e da bude jo jedna razvojna abnormalnost odgovorna za pankreatitis u dece.

Kljucne reci:

funkcionalna dispepsija,

podgrupe,

Helicobacter pylori.

The pancreas begins as two separate outpouchings arising

from oposite side of the caudal portion of the foregut

in a 3-4week-old embryo (1). The dorsal primordium is to

first to arise from the posterior duodenal wall (2). The ventral

pancreatic component begins as diverticulum from the

base of the ventrally positioned hepatic diverticulum (2).

This portion of the pancreas usually develop a bifid structure

with a right and left ventral pancreatic lobe (bilobed

embryonal ventral pancreas) (1,2). Further on, the ventral

pancreatic segment usually becomes singular, whether by

fusion of these lobes or by atrophy of the left lobe (1,2,3).

Then, the ventral anlage undergoes clockwise rotation to

rest just inferior and posterior to the dorsal pancreatic segment.

Fusion of dorsal and ventral pancreatic primordium

at 7-8 weks of embryonic life result in a mature pancreas

(4). If the 2 pancreatic primordium and their ductal system

do not fuse, the congenital anomaly of pancreas divisum

results (1,2,4,5).

The anomaly of duplex ventral pancreas is when both

left and lateral ventral pancreatic lobes ductal systems persists

after clockwise rotation and fusion of one of them

with dorsal pancreas.

Here we report the paediatric case of duplex ventral

pancreas presented as recurrent pancreatitis.

CASE REPORT

A 4.5-year old boy has been suffering of seven attacks

of acute pancreatitis for about 1.5 year. His clinical findings

was unremarcable. Laboratory investigations revealed

elevated serum and urinary amylase level, 1580 and 4320

IU/L respectivelly. Serum electrolytes, lipid profile, sweat

chloride concentration, stool examination for ova and parasites

were either normal or negative. An abdominal ultrasound

scan was normal. Endoscopic retrograde cholangiopancreatography

(ERCP) showed complete duplication

of ductal system. Both ductal systems filled by injection of

contrast material through the major papilla into the large

papillary ampulla. Figure 2. The upper ductal system

appeared normal. The lower ductal system was sligtly

dilated with irregular caliber. The patient is treated conservatively

with omeprazole 20mg/daily, pancreatic enzyme

supplementation and dieting. A six months follow up

showed two mild flares of pancreatitis.

DISCUSSION

During embryological development, the ventral pancreatic

primordium has complicated route of transformation

(6). This portion of pancreas usually develop bifid (bilobated)

appearance with a right and left ventral lobe.

Although this initial structure may become important in

the production of the annular pancreas, the ventral pancreatic

segment usually become singular, either by fusion of

these lobes or by atrophy of the left lobe. If the fusion

doesdraining the entire gland via the major papilla.

A review of the literature regarding pancreatic ductal

variation of the ventral pancreas has revealed one reference

to the anomaly of the ventral pancreas in two adult patients

reported by Agha (7). Both cases suffered of recurrent pancreatitis.

As in our paediatric patient, in both adult cases of

Agha only one ductal system was diseased (7). This lead us

to speculate that this ductal anomaly may predispose do

pancreatitis.

REFERENCES:

1.        Taylor AJ, Bohorfoush AG. Interpretation of ERCP.

Philadelphia:Lipincott, 1997.

2.        Belber JP, Bill K. Fison anomalies of the pancreatic

ductal system: differentiation from pathologic

states. Radiology 1977; 123:637-42.

3.        Glazer GM, Margulis AR. Annular pancreas: etiology

and diagnosis usind endoscopic retrograde

cholangiopancratography. Radiology 1979;

133:303-8.

4.        Delhaye M, Engelholm L, Cremer M. Pancreas

divisum: congenital anatomic variant or anomaly?

Contribution of endoscopic retrograde dorsal pancreatography.

Gastroenterology 1985; 89:951-8.

5.        Cotton PB. Congenital anomaly of pancreas divisum

as cause of obstructive pain and pancreatitis.

Gut 1980; 21:105-14.

6.        Freeny PC, Lawson TL. Embryology of the pancreas

and biliary tract. In: Freeny PC, Lawson TL,

eds. Radiology of the pancreas. New

York:Springer Verlag, 1982;pp 98-144.

7.        Agha FP. Duplex ventral pancreas. Gastrointest

Radiol 1987; 12:23-5.