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.
