Low Fat and Protein Therapy for Divisum Relapsing-Pancreatitis

Background: Acute Pancreatitis (AP) is the leading gastrointestinal emergency. It results from premature intracellular activation of trypsinogen or intraductal obstruction of pancreatic enzymes. Gall stones, alcohol and hypertriglyceridemia are the leading causes with Pancreatic Divisum (PD) representing a rare one. The case: A 58-year-old man presented with severe and progressive epigastric pain following ingestion of a fatty meal and red meat. The patient had a similar attack 3 months ago which was associated with high amylase and lipase, disclosing a self-limited AP. He did not have a previous history of medical, surgical disease, allergy, cigarette smoking, alcohol consumption or family history of pancreatitis. On admission he had high serum amylase at 724 IU/L (Normal: 28 - 100) and lipase at 15000 IU/L (Normal: 13 - 60). Investigations excluded other culprits: infections, autoimmune diseases, IgG4-disease, and genetic disorders. Magnetic Resonance Cholangiopancreatography disclosed PD with complete separation of dorsal and ventral parts and severe pancreatitis limited to the ventral part (head & uncinate process) with its duct draining into minor pancreatic papilla while dorsal part drains into the major papilla. There was no evidence of biliary disease, obstructive lesion, malignant disease or pseudocyst formation. Since the mechanism of such recurrent AP in PD is inadequate drainage of pancreatic enzymes stimulated by cholecystokinin, the patient was treated conservatively and subsequently with a diet low in fat and red meat. He improved within a few days and remained stable clinically and on laboratory testing up to 2 years. Conclusion: Mild recurrent AP associated with PD is amenable to a low-fat and protein diet.