Endoscopic appearance of the minor papilla predicts findings at pancreatography

The minor papilla serves as a site of alternative pancreatic duct drainage via the accessory pancreatic duct.

The objectives of this study were to assess the endoscopic appearance of the minor papilla for characteristics that might predict increased accessory pancreatic duct flow and hence suggest pathology of the downstream pancreatic ductal system.

This was a nonrandomized, prospective analysis of consecutively enrolled patients from a tertiary care medical center (Maine Medical Center, Portland, Maine). The study cohort consisted of consecutive patients presenting for endoscopic retrograde cholangiopancreatography (ERCP) without prior pancreaticobiliary endotherapy or ductography.

Sixty-four patients received a minor papilla score prior to ERCP. A normal pancreatogram was found in 37 of 64 (57.8%) patients; the remaining 27 (42.2%) patients had an abnormal pancreatogram. The median minor papilla bulge score was 0.49 (range 0-3) in the normal pancreatogram group and 2 (range 0-3) in the abnormal pancreatogram group (P < 0.0001). The median minor papilla orifice score of those with a normal pancreatogram was 0 (range 0-2) compared to 2 (range 0-3) in the abnormal pancreatogram group (P < 0.001). The median minor papilla cumulative score of 1 (range 0-5) for the normal pancreatogram group was significantly less than that for the abnormal pancreatogram group (3, range 0-6, P < 0.0001), resulting in a sensitivity of 96.3% for an abnormal pancreatogram. The minor papilla orifice was noted to be either gaping or actively dripping pancreatic juice in four out of five patients with pancreas divisum.

A minor papilla without bulging or a visible orifice would suggest a normal pancreatogram at ERP. Conversely, an abnormal minor papilla, particularly a patent minor papilla orifice, should raise suspicion of pancreatic ductal pathology and can help direct pancreatic endotherapy at the major or minor papillae.