Compilation of curvilinear-array EUS imaging demonstrating variant pancreatic ductal anatomy with radiologic corroboration and motion animation

Abstract

Congenital anatomic variants of the pancreatic duct are rare. Variant anatomy may be discovered incidentally or it may cause a wide range of symptoms. EUS is a minimally invasive diagnostic test for anatomic variants in the pancreatic duct. The aim of this video is to elucidate EUS images demonstrating 3 different variants of the pancreatic ductal anatomy with radiologic corroboration and motion animation (Video 1, available online at www.VideoGIE.org). The first patient was a 48-year-old woman with a history of chronic abdominal pain and idiopathic recurrent acute pancreatitis. She had persistent symptoms after cholecystectomy and was receiving long-term narcotic agents. Evaluation by MRI and laboratory studies at an outside hospital were unrevealing. EUS evaluation showed a dominant dorsal pancreatic duct (PD) draining into the minor papilla, compatible with pancreas divisum (Fig. 1A). Repeated MRI with secretin confirmed the diagnosis of pancreas divisum (Fig. 1B). The patient underwent ERCP with minor papilla sphincterotomy and balloon sphincteroplasty. She had complete relief of pain without recurrent pancreatitis during a 1-year follow-up. Figure 1 A, Left, probe of a linear echoendosocope facing the minor papilla in a representative case of pancreas divisum. Right, corresponding EUS image showing drainage of the dominant pancreatic duct (PD) into the minor papilla. B, MRI image showing drainage of a dominant pancreatic duct into the minor papilla (red arrow), compatible with pancreas divisum diagnosis. C, Left, probe of a linear echoendosocope facing the ampulla in a representative case of pancreaticobiliary maljunction. Right, corresponding EUS image showing the pancreaticobiliary maljunction resulting in a long common channel. D, MRI demonstrating the pancreaticobiliary maljunction and a 15-mm-long common channel. E, Follow-up MRI from a patient with side-branch intraductal papillary mucinous neoplasia in the head of the pancreas, revealing a bifid pancreatic duct (red arrow). F, Curvilinear echoendoscopic view from the stomach showing a bifurcated pancreatic duct arising from the body of the pancreas. CBD, common bile duct. The second patient was a 52-year-old woman with chronic, vague upper-abdominal pain. Her review of systems was otherwise unremarkable. Investigations revealed normal results of liver blood tests, EGD, and CT scan. EUS showed an anomalous junction between the pancreatic duct and the bile duct outside the duodenal wall, resulting in a long common channel (Fig. 1C). MRI confirmed the EUS findings (Fig. 1D). Because of the higher risk of gallbladder cancer associated with pancreatobiliary maljunction, prophylactic cholecystectomy was recommended. The third patient was a 75-year-old woman with a history of asymptomatic side-branch intraductal papillary mucinous neoplasia (IPMN). Follow-up imaging with MRI revealed a bifid pancreatic duct arising from the body of the pancreas (Fig. 1E). This finding was also well observed and illustrated by EUS evaluation (Fig. 1F). No relevant clinical significance related with bifid PD has been reported in the literature, and the patient continues to receive imaging surveillance of the side-branch IPMN. Although noninvasive imaging such as US, CT, and MRI are accurate diagnostic tests for anatomic variants in the pancreas, as illustrated in these cases, some patients may receive misdiagnoses. EUS is a safe and reliable test for diagnosing variant pancreatic ductal anatomy in patients with high clinical suspicion and nondiagnostic noninvasive imaging test results. Disclosure All authors disclosed no financial relationships relevant to this publication.