**5. Pancreas divisum**

Pancreas divisum (PD) is the most common anatomical variant of the pancreatic duct with an incidence of approximately 10% in the general population and symptomatic in only 5% of the patients [22]. PD has been shown to be a predisposing factor for chronic and recurrent pancreatitis and an incidental finding in idiopathic pancreatitis. However, its exact etiological role in pancreatitis is not well understood and still under study [23].

Contrast-enhanced CT and contrast-enhanced MRCP can be used in the diagnosis of PD with improved sensitivities with secretin provocation for better visualization of the ducts.

### *ERCP and EUS in Management of Pancreatitis DOI: http://dx.doi.org/10.5772/intechopen.108874*

Endoscopic Ultrasound (EUS) has also been reported to have a high diagnostic accuracy for PD with a sensitivity of 87–95% with secretin enhancement (S-EUS) offering marginal benefit. Absence of a "stack sign" and the presence of a "crossed duct sign" are considered to be indicative of PD. ERCP is seldom used if no therapeutic interventions are intended due to the associated risks [23].

Therapeutic interventions are reserved for patients with recurrent attacks of acute pancreatitis, incases of a single episode of severe pancreatitis in the absence of any other identifiable etiology or in chronic pancreatitis with a modifiable target such as a stone, dilated dorsal duct or stricture [23]. Endoscopic and surgical therapies can be employed on the management of PD. Endoscopic therapy includes minor papilla endoscopic sphincterotomy, minor papilla orifice balloon dilatation and trans minor papilla dorsal duct stenting.

Papillary endotherapy is associated with an increased risk of post-procedural pancreatitis and therefore prophylactic temporary pancreatic stenting is recommended in addition to peri-procedural non-steroidal anti-inflammatory drugs (NSAIDs) are recommended to reduce the risk. Long-term dorsal pancreatic duct stenting though effective, is associated with possible complications such as occlusion, ductal perforation, acute pancreatitis and proximal or distal stent migration.

Surgical therapy includes surgical minor papilla sphincterotomy or surgical minor papilla sphincteroplasty.

For both endoscopic and surgical therapies, the response rate to therapy is higher in the recurrent pancreatitis group compared to chronic pancreatitis and the chronic pancreatic-type abdominal pain (76–80% Vs 42%- 69% Vs 33–54% with endotherapy and 83% Vs 67% Vs 52% with surgical therapy) [23]. Due to comparable response rates with both endoscopic and surgical therapies, endoscopic therapy is recommended as first line due to a more favorable complication and mortality rate. Surgery is preserved for patients with failed minor papilla cannulation, endotherapy or have altered anatomy such as Bilroth II anatomy [23].
