Case Presentation: A 51-year-old gentleman with a history of chronic pancreatitis likely secondary to alcohol, presented with two to three weeks of nonspecific right sided abdominal pain and jaundice. On his initial admission his total bilirubin was 9.4 (normal 0.1 – 1.2 mg/dl). An abdominal computed tomography showed a complex hypodense region in the uncinated process of the pancreas measuring 0.8 cm x 1.2 cm along with mild pancreatic duct dilatation. On further examination of imaging, there was also suggestion that the major pancreatic duct drained in a separate location than the common bile duct. The patient was given ciprofloxacin for cholangitis prophylaxis while he underwent an endoscopic retrograde cholangio-pancreatography (ERCP). A biliary stricture was seen in the common bile duct along with pancreas divisum; unfortunately, the endoscopist was unable to negotiate the guidewire across the obstruction due to the tortuosity of the ducts. Thus, a Rendez-Vous procedure was planned with interventional radiology to obtain adequate biliary drainage. In this operation, a catheter was inserted into the liver segment 7/8 of the dilated bile duct through a percutaneous transhepatic approach. The tip was then advanced through the sphincter of Oddi and into the proximal jejunum. ERCP was then performed hours later under endosonographic and radiographic guidance. The previous tip inserted by interventional radiology was used as assistance to traverse through the stricture where a biliary stent was then placed. Afterwards, there was good flow of bile distally. The patient tolerated the procedure well and would have downtrending bilirubin levels with one biliary stent exchange (and subsequent upsizing) a few days alter.

Discussion: Pancreas divisum occurs when the dorsal and ventral buds of the embryonic pancreas do not fuse together, leading to separate pancreatic ducts and major/minor papilla. ERCP can diagnose this anatomy by cannulation of the two different distal openings to the duodenum. This condition, whether complete or incomplete, is a variant of pancreaticobiliary malunion that can lead to stenosis of the common bile duct, which unfortunately occurred in this case. This leads to recurrent attacks of pancreatitis as well as obstructive cholangitis.

Conclusions: Although pancreas divisum is the most common congenital anatomic variation of pancreatic anatomy and rarely symptomatic, in this case a multidisciplinary step approach was used to comprehensively diagnose and treat a challenging problem. Cannulation and sphincterotomy of papilla for recurrent pancreatitis have been done with the innovative Rendez-Vous procedure several times in the gastroenterology literature. However, this has not been characterized very well in patients with pancreas divisum. Resolution of symptoms was achieved with this innovative operation here, and should be considered for other stenotic ductal diseases.

IMAGE 1: ERCP Rendezvous