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

Discussion

Pancreas bifidum (also known as bifid pancreas or fishtail pancreas) is an exceedingly rare foregut anomaly, which comprises congenital branching of the pancreatic tail, including the main pancreatic duct.[2] The entity has not been well investigated and is usually an incidental finding requiring no treatment. We found 12 case reports in the literature describing "pancreas bifidum" or a "bifid pancreas" or "bifid tail of the pancreas", three of which were associated with pancreatitis,[3–5] and only one report where the pancreatitis involved only a single limb of a bifid pancreatic tail.[3] There was a single case report describing a bifid neck with a common head,[6] and three cases describing bifid pancreatic ducts without mention of an actual anatomic bifid tail.[7–9] The case that we are presenting in this report is believed to be the second case ever described that demonstrates acute pancreatitis in a single limb of a bifid pancreatic tail. Further, we believe that findings consistent with small acute necrotic collections localized to the affected limb make our case unique and the first to be reported.

This case is being highlighted because of its novelty and in order to raise the following potentially relevant clinical questions. Does having a bifid pancreas predispose to a higher probability of developing acute pancreatitis or adversely affect severity in those patients that already have pancreatitis? If so, what steps could be taken to improve clinical outcome? Do patients with a bifid pancreas have a greater likelihood of having other concomitant developmental anomalies that may negatively impact the patient clinically? Does the presence of pancreas bifidum, by reason of its anomalous shape and possible increased volume/mass, predispose a patient to more severe organ injury in cases of blunt abdominal trauma?

Granted, these questions are difficult to investigate and have questionable clinical significance with so few reported cases. That notwithstanding, one potential solution in assessing whether the anomaly predisposes to the development or worsening of pancreatic disease may be to assess the duct anatomy of patients with pancreas bifidum if and when they come to clinical attention. They could be evaluated for unusual ductal anatomy and/or other anomalous features that may predispose them to developing acute pancreatitis or result in prolonging or even worsening it if it has already developed. If a positive correlation is eventually discovered, consideration could be given to investigating possible preventative measures. In the case presented by Koyasu,[3] the authors assessed the patient's ductal anatomy with MRCP, but did not detect any abnormalities that might have contributed to the patient developing acute pancreatitis. Obviously, a single case is hardly precedent setting, raising the question whether patients found to possess the anomaly might benefit from investigative abdominal MR/MRCP. Perhaps as the number of cases of this entity grows over time, a clinical pattern may emerge that could help answer questions such as those detailed above and possibly assist clinicians in more effectively working up patients with this extremely rare developmental anomaly.

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