1. Endoscopic Retrograde Pancreatography
Olga Barkay, Evan L. Fogel, James L. Watkins, Lee McHenry, Glen A. Lehman, Stuart Sherman 
Clinical Gastroenterology and Hepatology 
Volume 7, Issue 9, Pages (September 2009)
DOI: /j.cgh
Copyright © 2009 AGA Institute Terms and Conditions

2. Figure 1
Anatomy and embryology of normal pancreas and pancreas divisum.
Clinical Gastroenterology and Hepatology 2009 7, DOI: ( /j.cgh )
Copyright © 2009 AGA Institute Terms and Conditions

3. Figure 2
Variants of pancreatic ductal anatomy. (a) The main pancreatic duct drains through the major papilla. The accessory duct is patent and drains through minor papilla. (b) Same as (a), except that the minor papilla is not patent, and the accessory duct and branches terminate near the duodenal wall. (c) The main pancreatic duct extends caudally in an ansa contour. (d) Complete pancreas divisum with a small ventral duct draining through the major papilla. There is a large dorsal duct draining through the minor papilla. (e) Incomplete pancreas divisum with a small branch connecting the ventral and the dorsal pancreatic ducts. (f) A variant of pancreas divisum in which the entire pancreatic ductal system drains through the minor papilla. There is no pancreatic duct connecting to the major papilla. (g) The same as (f) except that the dorsal pancreatic duct extends caudally in a “half-loop” configuration. (h) Complete pancreas divisum with saccular dilation of the terminal part of the dorsal pancreatic duct (Santorinicele). (i) Reversed pancreas divisum with the accessory ductal system draining a small portion of the pancreatic parenchyma through the minor papilla. There is no connection between the main and accessory ducts. Reproduced with permission from the Indiana University School of Medicine's Office of Visual Media.
Clinical Gastroenterology and Hepatology 2009 7, DOI: ( /j.cgh )
Copyright © 2009 AGA Institute Terms and Conditions

4. Figure 3
Normal pancreatogram. (A) Normal main pancreatic duct up to the tail of the pancreas. (B) A magnified view of the normal main pancreatic duct in the head and the body of the pancreas in the same patient. Note the finely tapered side branches.
Clinical Gastroenterology and Hepatology 2009 7, DOI: ( /j.cgh )
Copyright © 2009 AGA Institute Terms and Conditions

5. Figure 4
Complete pancreas divisum. (A) Contrast injection through the minor papilla shows the entire dorsal duct with no communication with the ventral duct. (B) Injection through the major papilla opacifies a small ventral duct with its terminal branches.
Clinical Gastroenterology and Hepatology 2009 7, DOI: ( /j.cgh )
Copyright © 2009 AGA Institute Terms and Conditions

6. Figure 5
Incomplete pancreas divisum. Contrast injection through the major papilla fills the dorsal pancreatic duct through the small communicating branch (arrow). There is a cystic dilation of the terminal part of the dorsal pancreatic duct (Santorinicele, arrowhead).
Clinical Gastroenterology and Hepatology 2009 7, DOI: ( /j.cgh )
Copyright © 2009 AGA Institute Terms and Conditions

7. Figure 6
Annular pancreas and pancreas divisum. Contrast injection through the major papilla shows a short ventral duct with an annular branch encircling the descending duodenum.
Clinical Gastroenterology and Hepatology 2009 7, DOI: ( /j.cgh )
Copyright © 2009 AGA Institute Terms and Conditions

8. Figure 7
Ansa pancreatica. A guidewire has been advanced around the loop to the neck of the pancreas.
Clinical Gastroenterology and Hepatology 2009 7, DOI: ( /j.cgh )
Copyright © 2009 AGA Institute Terms and Conditions

9. Figure 8
(A) Radial endosonography from the duodenum shows normal pancreatic duct in the head of the pancreas. (B) Radial endosonography from the stomach shows normal pancreatic duct in the body of the pancreas. PD, pancreatic duct; CBD, common bile duct; PV, portal vein; HA, hepatic artery; CONF, confluence; BOP, body of the pancreas; SV, splenic vein; LRV, left renal vein. (C) Normal pancreatic duct as shown by secretin-enhanced MRCP.
Clinical Gastroenterology and Hepatology 2009 7, DOI: ( /j.cgh )
Copyright © 2009 AGA Institute Terms and Conditions

10. Figure 9
(A) MRCP shows multiple side-branch cysts involving the whole pancreas, suggestive of a multifocal side-branch IPMN. (B) EUS image in the same patient shows one of the cysts with mural nodule, suspicious for malignancy. SV, splenic vein; BOP, body of pancreas.
Clinical Gastroenterology and Hepatology 2009 7, DOI: ( /j.cgh )
Copyright © 2009 AGA Institute Terms and Conditions

11. Figure 10
Secretin-enhanced MRCP (A) in a 60-year-old man with a history of idiopathic acute pancreatitis shows a stricture in the neck-body of the pancreas (arrow), with upstream dilation of the pancreatic duct. MRI in the same patient (B) shows a mass (arrow) in the neck-body of the pancreas. These data obviate the need for ERCP.
Clinical Gastroenterology and Hepatology 2009 7, DOI: ( /j.cgh )
Copyright © 2009 AGA Institute Terms and Conditions

12. Figure 11
Main duct IPMN. Note multiple filling defects (arrows) representing mucus in the dilated main pancreatic duct.
Clinical Gastroenterology and Hepatology 2009 7, DOI: ( /j.cgh )
Copyright © 2009 AGA Institute Terms and Conditions

13. Figure 12
(A) Secretin-enhanced MRCP shows extravasation of the contrast from the pancreatic duct in the tail of the pancreas (arrow). Initial contrast injection into the pancreatic duct during ERP shows a stricture in the body-tail of the pancreas (B, arrows), with no extravasation seen in the tail (C). Having known the results of MRCP, we injected more contrast in the tail, with resultant demonstration of the pancreatic duct leak (D, arrow).
Clinical Gastroenterology and Hepatology 2009 7, DOI: ( /j.cgh )
Copyright © 2009 AGA Institute Terms and Conditions

14. Figure 13
(A) Abdominal CT scan in an elderly woman with steatorrhea and weight loss shows a large calcified intraductal stone (arrowhead), with severe dilation of the upstream main pancreatic duct (arrows). (B) A dilated main pancreatic duct with prominent side branches in the head of the pancreas. A large radiopaque stone (arrow) prevents opacification of the upstream duct. (C) Partial visualization of the main pancreatic duct (arrows) upstream to the stone (arrowhead) is achieved. Note that with forceful contrast injection, the pancreatic duct stone moved to the junction of the neck and body of the pancreas.
Clinical Gastroenterology and Hepatology 2009 7, DOI: ( /j.cgh )
Copyright © 2009 AGA Institute Terms and Conditions

15. Figure 14
A large pancreatic stone with acoustic shadow in the pancreatic duct at the genu of the pancreas as seen by EUS. PD, pancreatic duct; CONF, portal confluence.
Clinical Gastroenterology and Hepatology 2009 7, DOI: ( /j.cgh )
Copyright © 2009 AGA Institute Terms and Conditions

16. Figure 15
A loop configuration of the otherwise normal main pancreatic duct as shown by secretin-enhanced MRCP.
Clinical Gastroenterology and Hepatology 2009 7, DOI: ( /j.cgh )
Copyright © 2009 AGA Institute Terms and Conditions

17. Figure 16
Complete pancreas divisum as demonstrated by secretin-enhanced MRCP (A). Note the dorsal pancreatic duct (arrows), which is not connected to the ventral pancreatic duct (arrowhead). (B) EUS shows a pancreatic duct (red arrow) that does not cross the border (black arrow) between the ventral (Ventr) and dorsal (Dors) portions of the pancreas, raising suspicion of pancreas divisum.
Clinical Gastroenterology and Hepatology 2009 7, DOI: ( /j.cgh )
Copyright © 2009 AGA Institute Terms and Conditions

18. Figure 17
Technique of pancreatic duct cannulation. (A) The duodenoscope facing the papilla en face, with the catheter oriented in straight on direction. (B) Pancreatic orifice location on the major papilla surface. Reproduced with permission from The Indiana University School of Medicine's Office of Visual Media.
Clinical Gastroenterology and Hepatology 2009 7, DOI: ( /j.cgh )
Copyright © 2009 AGA Institute Terms and Conditions

19. Figure 18
Duodenoscope in a long position for minor papilla cannulation in a patient with complete pancreas divisum. Injection of contrast through the minor papilla fills the entire dorsal duct. There is no communication with the ventral duct.
Clinical Gastroenterology and Hepatology 2009 7, DOI: ( /j.cgh )
Copyright © 2009 AGA Institute Terms and Conditions

20. Figure 19
EUS-assisted pancreatography. Contrast is injected into the pancreatic duct via the transgastric route under EUS and fluoroscopic guidance in patient after failed retrograde cannulation of the main pancreatic duct.
Clinical Gastroenterology and Hepatology 2009 7, DOI: ( /j.cgh )
Copyright © 2009 AGA Institute Terms and Conditions

21. Figure 20
(A) Acinarization of the dorsal pancreas in the upper head in a patient with pancreas cancer (contrast injection via the minor papilla). Note that a biliary stent has been placed. (B) Obstruction of the ventral pancreatic duct with mild acinarization in the same patient (contrast injection via the major papilla).
Clinical Gastroenterology and Hepatology 2009 7, DOI: ( /j.cgh )
Copyright © 2009 AGA Institute Terms and Conditions

22. Figure 21
Cutoff of the main pancreatic duct in the head of the pancreas in a patient with carcinoma in the head of the pancreas (pseudodivisum). Note abrupt termination of the main duct in the pancreatic head.
Clinical Gastroenterology and Hepatology 2009 7, DOI: ( /j.cgh )
Copyright © 2009 AGA Institute Terms and Conditions

23. Figure 22
(A) Mild chronic pancreatitis with normal-appearing main pancreatic duct (arrow). The side branches are dilated and irregular (arrowheads). (B) Secretin-enhanced MRCP in the same patient shows identical findings.
Clinical Gastroenterology and Hepatology 2009 7, DOI: ( /j.cgh )
Copyright © 2009 AGA Institute Terms and Conditions

24. Figure 23
Moderate chronic pancreatitis. Note the dilated and irregular main pancreatic duct with abnormal side branches.
Clinical Gastroenterology and Hepatology 2009 7, DOI: ( /j.cgh )
Copyright © 2009 AGA Institute Terms and Conditions

25. Figure 24
Stricture in the main pancreatic duct in a patient with severe chronic pancreatitis (arrow).
Clinical Gastroenterology and Hepatology 2009 7, DOI: ( /j.cgh )
Copyright © 2009 AGA Institute Terms and Conditions

26. Figure 25
Multiple stones in the main pancreatic duct in a patient with severe chronic pancreatitis.
Clinical Gastroenterology and Hepatology 2009 7, DOI: ( /j.cgh )
Copyright © 2009 AGA Institute Terms and Conditions