【双语病例】Pancreas divisum胰腺分裂

History and CT images

HistoryA 30-year-old woman presents with abdominal pain. She has a history of ulcerative colitis and is status post total proctocolectomy.

30岁女性,腹痛。曾有溃疡性结肠炎、全结肠直肠切除术后。

【双语病例】Pancreas divisum胰腺分裂

【双语病例】Pancreas divisum胰腺分裂

【双语病例】Pancreas divisum胰腺分裂

【双语病例】Pancreas divisum胰腺分裂

1.What is the etiology of the diagnosis?

图中所示异常改变的病因是什么?

Traumatic 外伤性

Congenital 先天性

Mechanical obstruction 机械性梗阻

Infectious 感染性

2.What is a possible presentation of patients who have this finding?

有这种异常改变的患者可能会有什么表现?

Pancreatitis 胰腺炎

Hyperbilirubinemia 高胆红素血症

Hematuria 血尿

Liver failure 肝功能衰竭

3.The finding is related to the patient’s diagnosis of ulcerative colitis.

图中所示的异常改变与患者的溃疡性结肠炎相关。

True

False

4.What is a potential treatment for symptomatic patients?

如果患者有症状,可以采取什么治疗手段?

Distal pancreatectomy 胰腺末端切除术

Lithotripsy 碎石术

Sphincterotomy 括约肌切开术

Cholecystectomy 胆囊切除术

【双语病例】Pancreas divisum胰腺分裂

【双语病例】Pancreas divisum胰腺分裂

选择题答案:

  1. Congenital
  2. Pancreatitis
  3. False
  4. Sphincterotomy

【双语病例】Pancreas divisum胰腺分裂

Findings and Diagnosis

【双语病例】Pancreas divisum胰腺分裂

【双语病例】Pancreas divisum胰腺分裂

【双语病例】Pancreas divisum胰腺分裂

【双语病例】Pancreas divisum胰腺分裂

FindingsThe dorsal pancreatic duct (yellow arrow), draining the pancreatic body and tail, is seen to empty through the accessory papilla, without definite connection to the shorter ventral pancreatic duct (blue arrow). The common bile duct (red arrow) joins the ventral pancreatic duct just proximal to the major papilla.

背侧胰管(黄箭头)贯穿胰腺体尾部,连于副乳头,与较短的腹侧胰管(蓝箭头)没有明确的连接。胆总管(红箭头)在靠近主乳头处与腹侧胆管相连。

There are no findings of acute pancreatitis.

图中所示无明显急性胰腺炎表现。

DiagnosisPancreas divisum

胰腺分裂

【双语病例】Pancreas divisum胰腺分裂

Discussion

Pancreas divisum (PD) is the most common congenital anatomic variant of the pancreas.  It occurs when there is a failure of fusion of the embryologic ventral and dorsal pancreatic ducts.  The embryologic dorsal bud develops into pancreatic body and tail, as well as the superior pancreatic head.It is drained by the dorsal pancreatic duct of Santorini.  The embryologic ventral bud develops into the uncinate process and the inferior pancreatic head, and is drained by the ventral duct of Wirsung.  When the dorsal and ventral buds fuse at 8 weeks of gestation, the two pancreatic ducts join and also fuse with the biliary ductal system and empty through the major papilla.  In PD, the dorsal duct fails to fuse with the ventral duct and instead empties through the smaller accessory papilla.

胰腺分裂(PD)是胰腺最常见的先天性解剖变异,是胚胎时期的腹侧胰管和背侧胰管融合异常所致。胚胎时期的胰腺背侧胚芽发育成胰腺体尾部和胰头上部,由Santorini管(副胰管)引流;腹侧胚芽发育成胰头下部和钩突,由Wirsung(主胰管)引流。

胚胎第8周时,腹侧胚芽和背侧胚芽融合,两条胰管也相互融合并与胆道系统连通。而PD患者,背侧胰管与腹侧胰管没有融合,独立开口于较小的副乳头。

Most cases of PD are asymptomatic and discovered incidentally on thin-section CT, MRCP, or ERCP performed for other reasons.  CT and MRI may demonstrate separate dorsal and ventral pancreatic moieties separated by a fat cleft.  T2-weighted MR images and MRCP easily depicts the ductal system and the lack of communication between the dorsal and ventral ducts.  This may occasionally be seen on thin-section CT as well.

大部分PD患者没有明显症状,多因其他原因进行薄层CT、MRCP或ERCP时偶然发现。CT、MRI可以显示独立的背侧胰腺和腹侧胰腺,中间有脂肪间隙分隔。磁共振T2WI和MRCP能清晰显示胰胆管的走形,可以发现背侧胰管和腹侧胰管不相通。有时,薄层CT也可以很好地显示这一征象。

PD is associated with idiopathic pancreatitis.  It was once thought that the smaller diameter minor papilla causes a relative obstruction, given the larger amount of pancreatic secretions from the longer dorsal duct.  However, since most cases are asymptomatic, it is currently thought that recurrent pancreatitis associated with PD is secondary to a stenotic minor papilla.  Patients with PD who present with pancreatitis can demonstrate typical imaging findings of pancreatic edema, peripancreatic inflammation, pseudocyst formation, and possible pancreatic necrosis.  With recurrent, chronic pancreatitis, the pancreas may become atrophied and the dorsal duct may become dilated.

PD与自发性胰腺炎相关。既往认为,背侧胰管较长,引流更多的胰液,副乳头较小会引起相对梗阻。但随着越来越多无症状PD患者的发现,目前更多人认为,PD伴反复发作的胰腺炎可能是由如乳头狭窄导致。PD患者发生胰腺炎典型表现为:胰腺水肿、胰腺周围渗出、假囊肿形成,还可能出现胰腺坏死。慢性胰腺炎反复发作,胰腺逐渐萎缩,背侧胰管扩张。

Recurrent pancreatitis secondary to PD may be treated by surgical sphincteroplasty or endoscopic sphincterotomy of the stenotic minor papilla.  A secretin test may be administered to determine whether there is obstruction at the minor papilla.  Dilation of the pancreatic duct greater than 2 mm following secretin administration, which increases pancreatic bicarbonate secretion, suggests obstruction at the minor papilla.  Pancreatic ductal dilation may be visualized with ultrasound or MRCP.  Patients with demonstrated obstruction are more likely to benefit from surgical or endoscopic intervention.

PD继发胰腺炎反复发作,可以通过手术或内镜对狭窄的副乳头行括约肌切开术。肠促胰液素实验可以使胰液分泌增加,如果胰管扩张直径超过2mm,提示副乳头梗阻,胰管的扩张在超声或MRCP上都可以很好地显示。证实为梗阻的患者,手术或内镜治疗效果很好。

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