Pancreas divisum pancreatitis: a case report Elena Gologan, 1 Dorin Achitei, 2 Roxana Bocan, 2 Gheorghe Balan 1 1 University of Medicine and Pharmacy, Gastroenterology, Iasi, Romania 2 Institute of Gastroenterology and Hepatology, Iasi, Romania Pancreas divisum is considered to be the most frequent congenital pancreatic abnormality but, depending upon the diagnostic method employed, wide ranges of inci- dence are reported [1]. At necropsy, the incidence is less than 14% but when using endoscopic retrograde chol- angiopancreatography (ERCP), the incidence reaches 25%, obviously due to the selection bias linked to studying a symptomatic population [2]. Imaging is essential for the diagnosis which is then confirmed by cholangiopancreatography, either using magnetic resonance or ERCP. This approach is prefer- rable due to its non-invasive character [3]. Contrast computed tomography and ultrasound examinations are not useful, except for the acute pancreatitis resulting from pancreas divisum; they reveal better the secondary parenchymal changes rather than allow the identification of the two separate, non-communicating ducts. The secretin test is not recommended because of its acute pancreatitis risk [3]. We present here an unusual case of pancreatitis in a patient with pancreas divisum in whom only one of the pancreatic areas was affected. In such situations imaging should consider all the pancreatic areas because even if one may appear normal, this does not exclude the exis- tence of pancreatitis lesions in the other. Case report A 19-year-old student presented to the Institute of Gastroenterology and Hepatology from Iasi, Romania with left hypochondral pain, irradiating to the upper abdomen, predominantly but not exclusively after meals. The patient had no significant family history. Notable in the patient’s history is an episode two weeks earlier of acute pancreatitis and bulbar duodenal ulcer, recently diagnosed in a district hospital where she was treated, No clear alimentary trigger could be identified at that time. The patient was a non-smoker and did not drink alcohol. She was not under any medication at the time the pan- creatitis symptoms appeared. Physical examination revealed mild left hypochondral and mesogastric pain at deep abdominal palpation. Laboratory tests revealed normal hematological values; biochemistry showed blood amylase 131 IU/L, urine amylase 811 IU/L, and blood lipase 237 IU/L. Calcium levels and inflammation biomarkers were normal (pos- sibly because the patient was admitted two weeks after the beginning of the pain, that was initially much more severe). Given the suspected clinical diagnosis of acute pan- creatitis, an ultrasound examination was performed which revealed an overall enlarged pancreas. The pan- creas head (Fig. 1) had a normal structure (uniform echogenicity slightly higher than the liver). The pancreas body and tail displayed a cephalic extension in the pos- terior plane and had a distinctly hypoechoic structure, rounded edges and was overall enlarged out of propor- tion in relation to the pancreas head (Fig. 1B). There were no dilatations of the pancreatic ducts and there were no necrotic areas or pancreatic and peripancreatic fluid collections. The biliary ducts, liver and spleen were normal. There was no fluid in the peritoneal cavity. Subsequently, the patient was explored endoscopi- cally in order to identify a gastric ulcer lesion, as de- scribed during a recent endoscopy. However, there were only inflammatory aspects of the gastro-duodenal mu- cosa, but no ulcer could be identified. Given the suspicion of acute pancreatitis due to pan- creas divisum suggested by the ultrasound examination and the exclusion of other more frequent causes of acute pancreatitis (alcohol consumption, biliary causes) as well as rare causes (dyslipidemias, hyperparathyroidism, trauma, drugs, allergy, autoimmunity, infections), a magnetic resonance cholangiopancreatograpy (MRCP) was car- ried out in order to identify ductal and parenchymatous Electronic supplementary material: The online version of this article (doi:10.1007/s00261-010-9619-3) contains supplementary material, which is available to authorized users. Correspondence to: Elena Gologan; email: elenagologan2007@yahoo. com ª Springer Science+Business Media, LLC 2010 Published online: 14 May 2010 Abdominal Imaging Abdom Imaging (2011) 36:215–217 DOI: 10.1007/s00261-010-9619-3