A Giant Santorini

A 29-year-old female presented to the emergency department with nausea, constipation and abdominal pain. Medical history was silent, with no tobacco smoking or significant alcohol consumption. Abdominal US and CT scan showed a normal gallbladder, no biliary duct dilation but parenchymal involution of the pancreas and marked dilation of the main pancreatic duct with a hyperdense body at the pancreatic head and dilation of secondary ducts. Blood tests showed elevated levels of amylase and lipase. A diagnosis of AP was made, moderate fluid resuscitation and pain management were performed. Due to low levels of fecal elastase, a diagnosis of CP was made. Tests for cystic fibrosis and autoimmune conditions were negative. An abdominal MRI and a EUS showed a 30 mm filling defect in the Santorini duct, with a dilation of 23 mm and no clear connection with the Wirsung duct. A differential diagnosis between Santorini duct obstruction and dorsal dominant duct was proposed. ERCP showed a thin Wirsung duct with a suspected pancreas divisum. Minor papilla cannulation confirmed massive dilation of the Santorini duct with filling defects in the distal part. After minor papilla sphincterotomy, successful Santorini duct drainage was achieved, and pancreatic stent was positioned. The patient was discharged and two months later cholangiography showed a less dilated dorsal duct with an extremely narrow connection to the Wirsung duct. The patient has not experienced a second episode of AP.

This case illustrates how anatomic anomalies of the pancreas can lead to CP and how AP could be caused by pancreatic duct obstruction. In some cases, ERCP remains the only way to differentiate complete pancreas divisum from the dominant Santorini condition.

Publication History

Article published online:
27 March 2025