Diagnostic aspects of incomplete pancreas divisum

from the stomach prior to the completion of the endoscopy, and the bubble remained in the proper position. David Glaser, MD George O. deTarnowsky, MD Albert Mason, MD Fountain Valley Regional Hospital Fountain Valley, California

REFERENCE 1. Garren M, Garren L, Giordano F. The Garren gastric bubble:

an Rx for the morbidly obese. Endosc Rev 1984;1:57-60.

Diagnostic aspects of incomplete pancreas divisum

of the Wirsung duct may be erroneously suspected, especially in cases in which the accessory papilla opens just above the papilla of Vater. In such cases differentiation is possible on the basis of the characteristic broom-like arborization ofthe ventral duct and by the absence of prestenotic dilation of the dorsal duct. It may happen that the connection between the two ducts is also opacified. Such a finding may give rise to the incorrect diagnosis of tumor causing circumscribed stenosis and arched dislocation of the duct. The characteristic radiological findings are helpful in establishing the right diagnosis. 3 Another aspect of incomplete pancreas divisum is that the connection between the two ducts may promote the drainage of the dorsal pancreatic duct. Thus, retention and obstructive pain may develop less frequently. Z. Tulassay, MD J. Papp, MD

To the Editor: Pancreas divisum is a congenital abnormality in which the embryonal pancreatic elements, the ventral and dorsal buds and the ducts, fail to fuse. The clinical significance of pancreas divisum is controversial. It has been suggested that it may cause acute recurrent pancreatitis. 1 - 3 Pancreas divisum is a rare anomaly occurring in 0.3% to 6% in various surveys. In our ERCP material involving 10,378 examinations we found 197 (1.9%) cases with pancreas divisum. Of them, 14 patients had incomplete pancreas divisum, a very infrequent duct abnormality. In these cases the ventral and dorsal duct communicate through secondary branches in spite of their separate development. 4 ,5 The visualization of the dorsal duct can be attained by cannulation of the papilla of Vater (Fig. 1). Incomplete pancreas divisum is of major clinical significance since it may lead to misinterpretation of ERCP findings. The presence of a connection between the secondary branches of the two ducts is not always evident in the majority of radiograms. As a consequence of this, abruption

First Medical Clinic Semmelweis University Budapest, Hungary

I. E. Farkas, MD Kerepestarcsa Hospital

REFERENCES 1. Cotton PB. Congenital anomaly of pancreas divisum as cause

of obstructive pain and pancreatitis. Gut 1980;21:105-14. 2. Tulassay Z, Papp J. New clinical aspects of pancreas divisum. Gastrointest Endosc 1980;26:143-6. 3. Warshaw AL, Richter JM, Schapiro RH. The cause and treatment of pancreatitis associated with pancreas divisum. Ann Surg 1983;198:443-52. 4. Gregg JA, Schweistris E, Antal R. Variant pancreatic duct anatomy, incomplete pancreas divisum (lPDj, is associated with obstructive pain, pancreatitis and biliary sphincter stenosis. Gastrointest Endosc 1985;31:142. 5. Farkas IE. Rare anomaly ofthe pancreatic duct: communication between the two ductal system in pancreas divisum. Diagn Imaging 1982;51:284-7.

Symptomatic cystic duct stones: the diagnostic value of endoscopic retrograde cholangiography To the Editor:

Figure 1. Visualization of the pancreatic ducts only by catheterization of the papilla of Vater. 428

The diagnostic methods most commonly employed in the workup of patients with biliary-like pain are ultrasonography and cholecystography. Both techniques are very sensitive in the diagnosis of gallbladder stones. 1• 2 We report a patient with persistent biliary-like pain in whom extensive workup, including ultrasonography, cholecystography, abdominal CT, and repeated liver function tests, was normal. The diagnosis of cystic duct stones was incidentally made only after endoscopic retrograde cholangiography (ERC) was performed. A 37-year-old woman was referred for evaluation of episodes of right upper quadrant pain. Pain was associated with nausea, lasted a few hours, and was unrelated to meals. Physical examination was normal. Extensive laboratory evaluation, including liver chemistry, was normal. Abdominal ultrasonography showed the gallbladder and the intraGASTROINTESTINAL ENDOSCOPY