Predicting pancreas divisum by inspection of the minor papilla: a prospective study

BACKGROUND: Minor papilla (MP) cannulation remains difficult in some patients despite improved cannulation devices and techniques. Therefore, noninvasive methods to predict presence of pancreas divisum (Pdiv) are desired. If Pdiv could be recognized before any cannulation is attempted, appropriate attention could be focused on MP cannulation and prolonged major papilla attempt at pancreatogram can be avoided. AIM: To evaluate whether simple inspection of the MP during initial duodenal entry during endoscopic retrograde cholangiopancreatography (ERCP) can predict the presence of Pdiv. METHODS: Patients undergoing ERCP with intended pancreatic duct cannulation were included in the study. Assessment of the MP was made during a 30 to 60-second period of inspection including aspiration of duodenal luminal air with the endoscope. The probability of Pdiv based on the appearance of the MP was then estimated by assessing the size of the MP, the diameter of MP orifice, and whether juice was seen draining through the MP orifice. RESULTS: Two hundred and twelve patients were prospectively analyzed. The most common indications for ERCP were suspected sphincter of Oddi dysfunction (44.3%) and idiopathic pancreatitis (34.4%). Pancreatograms revealed Pdiv in 42 (19.8%). The MP appearance had 54.7% sensitivity and 90% specificity in detecting Pdiv (positive predictive value 57.5%, negative predicting value 88.9%). Seventy percent of the false positive patients had an obstructing pathology at the ventral duct that would explain the MP appearance. CONCLUSIONS: Certain features of the MP (enlarged papilla, open orifice) had a moderate predictive value for the presence of Pdiv or an obstruction at the major papilla. However, a significant number of patients with Pdiv did not have these features.