Post written by Rungsun Rerknimitr, MD, FRCP (London), FASGE, from Chulalongkorn University, Bangkok, Thailand.

Our case is about a 10-year-old girl with known tropical chronic pancreatitis with mutation at the transition c.206C>T in exon 4 of the SPINK1 gene who underwent pancreatic sphincterotomy via major papilla with pancreatic stone extraction 6 months prior.

The patient presented with a new episode of epigastric pain and elevation of serum amylase and lipase levels requiring opioid infusion to control pain. A CT scan of the upper abdomen demonstrated a new dilation of the dorsal duct only at the pancreatic head and genu suspicious for reverse pancreas divisum (Fig. 1). Dorsal duct drainage to relieve the obstruction was considered. A standard cannulation of the minor papilla failed.

A precut on the minor papilla was performed (Fig. 2), and a 0.025-inch guidewire was able to access the dorsal duct with significant difficulty to pass a 6F catheter. A dorsal pancreatogram confirmed the finding of reverse pancreas divisum with amorphous filling defect in the dorsal duct (Fig. 3).

After a 6-mm balloon pancreatic papilloplasty via the minor papilla, a single operator pancreatoscope was inserted. Pancreatoscopy revealed soft-white pancreatic protein plugs (Fig. 4) that easily gushed out to the duodenum after water irrigation.

After the procedure, the patient reported subsided pain and was able to resume a regular diet in a few days.

Dilated dorsal duct at the pancreatic head on a CT scan (white arrow).

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