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Date: 2014-03-30

DOI: http//dx.doi.org/10.13070/rs.en.1.655

ISSN : 2334-1009

Duplication of the pancreatic duct - diagnosis on MRCP

Makarand Kulkarni - MDDepartment of Radiology, Lilavati hospital and Research Centre, Mumbai, India

Parangama Chatterjee MD - Department of Radiology, Lilavati hospital and Research Centre, Mumbai, India

Prasad Wagle MD - Department of Gastroenterology, Lilavati Hospital and Research Centre, Mumbai, India

Abstract:

Duplication of the pancreatic duct is a relatively rare anomaly which is often missed on imaging. We present the imaging findings, embryology and differential diagnosis of this rare anomaly diagnosed on MRCP.


Case History:

A 50 year-old female patient presented with features suggestive of obstructive jaundice. The patient had a history of having undergone CBD stenting previously. Subsequently the patient had an endoscopy and biopsy which was suggestive of lower common bile duct cholangiocarcinoma. The patient underwent a Whipple's procedure two weeks later with a standard pancreaticoduodenectomy and pancreaticogastic anastomoses. It was a dunking procedure and no attempt was made to identify any duct or duct mucosa. The patient had an uneventful recovery post-operatively and was under regular followup. Four years after the procedure the patient started complaining of epigastic discomfort. A repeat CT scan showed a possibility of 2 ducts within the pancreas which were dilated. To confirm this, MRCP was performed which showed a duplicated pancreatic duct.


duplicated pancreatic duct

Figure 1. Coronal MIP images from MRCP showing a duplicated pancreatic duct, status post Whipple's.

Discussion:

Congenital anatomical variations of the pancreas usually encompass aberrations of draining of ducts, anomalies of fusion pancreas divisum, annular pancreas, pancreatic agenesis/hypoplasia, ectopic pancreas, and anomalies of duplication [1]. In a previous study of 485 patients undergoing endoscopic retrograde cholangiopancreatography [2], findings revealed congenital variations in 48 patients (9.9%), of these, 45.8% were duplex anomalies: 13 were main pancreatic duct bifurcations, which were subclassified as 4 loop type, 2 N-shaped, and 3 ring type. Duplication of the main pancreatic duct was seen at the head-body level in 6 cases and at the tail-body level in 7 cases. There are 2 previous reports of pancreatic duct bifurcation of the head level (duplicated ventral pancreas) [3] [4]. The primitive ventral pancreatic bud is formed of two lobes, the right and the left, of which the left regresses [4]. It is theorised that the persistence of the two lobes or the differentiation of one bud into two buds is the cause of a duplicated ventral pancreas [3], whereas the bifid pancreas seems to be the result of a bifid dorsal pancreatic duct [5].

Duplication of both the pancreatic duct and pancreatic parenchyma is very rare, partial duplication being more common. The incidence of duplication of the main pancreatic duct predominantly in the body and tail is around 10% [1]. There is an association of duplication of stomach or bowel which communicates with the main pancreatic duct and lobe through an abnormal duct [6]. Kikuchi et al [7] reported one case of duplication of the pancreatic tail in which the patient presented with features of a gastric submucosal tumour (duplicated pancreatic tail).

MRCP usually shows 2 parallel ducts in the pancreatic body or tail, with the duct showing variable course. Cross-sectional images may show an accessory pancreatic lobe in close relation to the stomach or bowel. The abnormal duct may sometimes lead to a cyst which often represents a duplication cyst of the stomach. Pancreatic duplications usually have more than than normal pancreatic tissue which may produce an extrinsic/pseudomass effect on US or CT [8] [9]. MRCP/ERCP is required in such patients to delineate the ductal anatomy and exclude pathological conditions. Differential diagnosis would include respiratory artefacts which may often simulate a partial duplication of the pancreatic duct due to misregistration.

Declarations:

All authors have contributed to and agreed on the content of the manuscript, roles are as follows: Dr. Makarand Kulkarni - study design, manuscript preparation and editing; Dr. Parangama Chatterjee - study design, manuscript preparation and editing; Dr. Prasad Wagle - study concepts, manuscript editing.

The manuscript has not been published previously, in any language, in whole or in part, and is not currently under consideration elsewhere.

Consent from the patient was obtained, ethics committee approval was obtained.

There were no conflicts of interest, and there was no external funding agency.

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