Radiological Case: Pancreas Bifidum With Acute Necrotizing Pancreatitis in a Single Limb

Steven L. Weiner, MD; Kenneth M. Zinn, MD; Thomas D. Olsavsky, MD

Disclosures

Appl Radiol. 2017;46(8):32-34. 

In This Article

Imaging Findings

CT imaging demonstrated pancreas bifidum with asymmetric enlargement of the ventral limb of the bifid tail when compared to the dorsal limb (Figures 1,2). The ventral component demonstrates inflammatory infiltration of the surrounding fat, as well as several peripancreatic and intraparenchymal areas of hypoattenuation best appreciated on the sagittal projection (Figure 2) that appear to involve greater than 30 percent of the inflamed ventral limb per the Revised Atlanta Classification of Acute Pancreatitis,[1] most compatible with small acute necrotic collections. These findings are consistent with mild acute necrotizing pancreatitis involving only the ventral limb of a bifid pancreatic tail. A follow-up CT exam (Figure 3) from approximately one and a half years after the current CT demonstrated a bifid pancreas, but no radiographic signs of pancreatitis or hypoattenuating areas.

Figure 1.

Contrast-enhanced axial CT of the upper abdomen demonstrating bifid pancreas (arrows) with findings consistent with acute pancreatitis of the ventral limb and a hypoattenuating parenchymal lesion suspicious for a small acute necrotic collection (black arrow). (Click on this image to view it in a DICOM viewer powered by EXA-PACS.)

Figure 2.

Contrast-enhanced sagittal CT of the upper abdomen again demonstrating a bifid pancreas (arrows) with acute necrotizing pancreatitis of the ventral limb (white arrow). Note hypoattenuating areas within the substance and periphery of the ventral limb pancreatic parenchyma (white arrow), believed to be acute necrotic collections.

Figure 3.

Follow-up contrast-enhanced axial CT of the upper abdomen on the same patient 1½ years later, again demonstrating pancreas bifidum, but with no signs of pancreatitis.

After gastroenterology consultation and appropriate follow-up care, endoscopic ultrasound (not shown) was performed six days after the patient's presentation in the emergency room, which demonstrated a hypoechoic pancreatic collection containing echogenic material within. Fine needle aspiration was performed during the endoscopic sonogram retrieving 3 cc of purulent material, consisting mainly of polymorphonucleocytes per the cytopathological evaluation. The patient was started on Cipro 250 mg p.o. bid. for seven days, with further recommendations pending the patient's clinical response and cytopathology culture results. The patient responded well to treatment and made a full recovery.

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