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Predicting pancreas divisum by inspection of the minor papilla: a prospective study
Waleed M Alazmi1, Patrick Mosler, James L Watkins
1Indiana University Medical Center, Indianapolis, IN 46202, USA.
Background:
Minor papilla (MP) cannulation remains difficult in some patients despite improved cannulation devices and techniques. Therefore, noninvasive methods to predict presence of pancreas divisum (Pdiv) are desired. If Pdiv could be recognized before any cannulation is attempted, appropriate attention could be focused on MP cannulation and prolonged major papilla attempt at pancreatogram can be avoided.
Aim:
To evaluate whether simple inspection of the MP during initial duodenal entry during endoscopic retrograde cholangiopancreatography (ERCP) can predict the presence of Pdiv.
Methods:
Patients undergoing ERCP with intended pancreatic duct cannulation were included in the study. Assessment of the MP was made during a 30 to 60-second period of inspection including aspiration of duodenal luminal air with the endoscope. The probability of Pdiv based on the appearance of the MP was then estimated by assessing the size of the MP, the diameter of MP orifice, and whether juice was seen draining through the MP orifice.
Results:
Two hundred and twelve patients were prospectively analyzed. The most common indications for ERCP were suspected sphincter of Oddi dysfunction (44.3%) and idiopathic pancreatitis (34.4%). Pancreatograms revealed Pdiv in 42 (19.8%). The MP appearance had 54.7% sensitivity and 90% specificity in detecting Pdiv (positive predictive value 57.5%, negative predicting value 88.9%). Seventy percent of the false positive patients had an obstructing pathology at the ventral duct that would explain the MP appearance.
Conclusions:
Certain features of the MP (enlarged papilla, open orifice) had a moderate predictive value for the presence of Pdiv or an obstruction at the major papilla. However, a significant number of patients with Pdiv did not have these features.
Insights
Minor papilla inspection during ERCP can help predict pancreas divisum (Pdiv). While certain features suggest Pdiv, a significant number of patients with Pdiv lack these indicators, necessitating further diagnostic approaches.
Area of Science:
- Gastroenterology
- Endoscopy
- Anatomical Variations
Background:
- Minor papilla (MP) cannulation is challenging in some patients.
- Predicting pancreas divisum (Pdiv) noninvasively can optimize ERCP procedures.
- Early Pdiv recognition can prevent prolonged attempts at the major papilla.
Purpose of the Study:
- To assess if MP inspection during ERCP predicts Pdiv.
- To evaluate the diagnostic utility of MP appearance for Pdiv detection.
Main Methods:
- Prospective analysis of 212 patients undergoing ERCP.
- MP assessment during a brief endoscopic inspection.
- Evaluation of MP size, orifice diameter, and bile drainage for Pdiv prediction.
Main Results:
- Pdiv was found in 19.8% of patients.
- MP appearance showed 54.7% sensitivity and 90% specificity for Pdiv.
- False positives were often linked to ventral duct obstruction.
Conclusions:
- MP features like enlargement and open orifice moderately predict Pdiv or major papilla obstruction.
- A notable proportion of Pdiv cases do not exhibit these predictive MP features.
