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Hepatobiliary and pancreatic: Isolated accessory pancreatic duct

During gestation, the pancreas develops from dorsal and ventral outpouchings from the primitive gut that later becomes the duodenum. By week 7, the dorsal and ventral buds are brought into apposition by rotation of the ventral bud and by the uneven growth of the duodenum. The two buds then fuse after which the duct of the ventral pancreas anastomozes with the duct of the dorsal pancreas to form the main pancreatic duct. Normally, the proximal end of the dorsal duct remains patent as the duct of Santorini and enters the duodenum through the accessory papilla. The primordial biliary system rotates with the ventral pancreas and ultimately results in a joint point of entry of the bile duct and main pancreatic duct into the duodenum. The most common ductal variant is malfusion of the ducts of the dorsal and ventral pancreas (pancreas divisum). Other ductal variants include anomalous pancreatobiliary junctions and perhaps choledochal cysts. A rarer ductal abnormality is illustrated below. Images were taken from a 58-year-old woman who was investigated because of a 4 week history of recurrent abdominal pain. Results of various blood tests including a plasma amylase were within the reference range. An upper abdominal ultrasound study and a computed tomography scan revealed an atrophic pancreas but no other abnormalities were detected. Because of the possibility of pancreatic disease, endoscopic retrograde pancreatography was performed. The major papilla was normal as were images of the main pancreatic duct (Fig. 1). However, despite reasonable filling of side-branches, no contrast passed into the accessory duct. The minor papilla was enlarged and edematous and radiographs showed a short pancreatic duct that failed to connect with the main pancreatic duct (Fig. 2). The minor papilla was removed by endoscopic resection and histological evaluation revealed a small adenoma. At magnetic resonance cholangiopancreatography, there was a normal bile duct and main pancreatic duct but the short accessory duct was not outlined. Endoscopic retrograde pancreatography was repeated after 18 months because of the remote possibility of a small pancreatic neoplasm. The findings were identical to those illustrated below. An accessory duct that is unconnected to the main pancreatic duct appears to be rare. A congenital anomaly would appear to be the most likely explanation but an alternative mechanism is ductal damage as a result of focal inflammation.