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Pancreas Divisum: A Congenital Pancreas Disorder

Complicated by Pancreatitis and Gastroparesis

Jessica Cowper, Dietetic Intern


Henry Ford Hospital
Case Study Project
June 13, 2017
Objectives
Introduce the patient
Define pancreas divisum, the etiology, signs and
symptoms, and possible treatments/management
Address additional diagnoses complicating
patients nutritional status
Pancreatitis
Gastroparesis
Obesity
Review the nutrition assessment, diagnosis,
interventions, monitoring and evaluation related to
patients admission course
Discuss related research and findings
Introduction
Personal: 30 year old female, single
Socioeconomic: BA in marketing management,
unemployed since 2013, previously lived in a group
home, currently lives with roommate in a house
Reason for admission: Recurrent epigastric
abdominal pain and intractable nausea and
vomiting
Past medical history: Chronic Pancreatitis with
Incomplete Pancreas Divisum and pancreatic
strictures with multiple pancreatic stent placements
and removals since 2008, gastroparesis,
hypothyroidism, steroid-induced diabetes requiring
Metformin (not currently prescribed), obesity,
bipolar disorder, anxiety, depression
Diagnoses: Pancreas Divisum
Incomplete Pancreas divisum
A congenital disorder where the ventral and dorsal
ducts of the pancreas do not fuse together in the
embryo
When this happens, the major drainage of the
pancreas is done via the smaller duct, the dorsal duct,
which opens into the minor papilla
Because the drainage is going through a tiny opening
into the duodenum, not all the pancreatic juices may
drain, which can cause complications to arise due to
the higher pressure in the duct
Epidemiology:
Pancreas Divisum
It is the most common congenital pancreatic anomaly,
affecting 5-10% of the population
Incomplete pancreas divisum only affects 2% of the
population

In a retrospective study from India, the prevalence was


higher if the patient had pancreatitis rather than biliary
disease or nonspecific chronic abdominal pain (9 vs.
2%)

It is also more common to be seen in young females


Signs and Symptoms: Pancreas Divisum

Abdominal pain

Nausea and vomiting

Acute and chronic pancreatitis

Most patients are asymptomatic and ERCP is the


gold standard for diagnosis pancreas divisum

**It is still controversial whether the symptoms occurring are due to pancreas divisum, there are
studies that suggest it may be more related to genetic mutations **
Treatment & Management:
Pancreas Divisum
Medical & Nutrition Options:
Low Fat Diet
Analgesics
Pancreatic Enzymes
Anticholinergics

Endoscopic Options: (ERCP)


Minor Papilla Sphincterotomy: cutting the minor papilla to enlarge
the opening
Minor Papilla Dilation and Stenting: creates a larger opening in the
minor papilla by passing a dilating balloon/catheter to prevent
blockage, or a stent can be inserted to open a blocked duct

Surgical Options:
Puestow Procedure: surgical procedure where the minor papilla is
cut to enlarge the opening and is then connected to a loop of the
jejunum to allow for the pancreatic enzymes to drain directly into the
intestines

*Treatment depends on the severity of the pancreas disorder and based on the
discretion of the physician*
Puestow Procedure
Diagnoses: Pancreatitis
Inflammation of the pancreas that can be acute or chronic that
results in progressive exocrine and endocrine dysfunction, ultimately
leading to abnormal digestion, absorption, and utilization of
nutrients.
Chronic- diagnosed based on intermittent or constant upper
abdominal pain and other clinical symptoms as well as imaging
studies such as a CT scan, MRI, ERCP, endoscopic ultrasound,
etc.
Symptoms: pain in abdomen/back, bloating, fat in stool,
indigestion, nausea, vomiting, weight loss, loss of appetite, sweating
Causes: alcoholism, gallstones, abdominal surgery, medications,
pancreatic disorders, infection, cigarette smoking, etc.
Nutrition Implications: 20-50% increase in resting energy expenditure
indicates for kcal to be up to 35 kcal/kg, protein: 1-1.5 g/kg, 30% of
kcal from fat

80% of patients can be managed by a combination of analgesics, dietary


modifications, and pancreatic enzyme supplements, 10-15% need oral nutritional
supplements, 5% need enteral nutrition, and 1% require TPN
Diagnoses: Gastroparesis
Gastroparesis: Digestive disorder that affects the
motility and gastric emptying of the stomach; the
stomach cannot contract normally, therefore food
cannot be digested as easily
Causes: diabetes, infections, hypothyroidism,
autoimmune conditions, medications (ex: narcotics,
antidepressants, calcium channel blockers), eating
disorders, surgery or radiation therapy, etc.
Symptoms: bloating, nausea, vomiting, early satiety,
heartburn, epigastric pain, weight loss due to
malabsorption
Nutrition Implications: low fat and fiber diet, soft &
pureed consistencies, feeding tube if necessary
Diagnoses: Obesity
Obesity is defined as having more body fat than lean
muscle mass, diagnosed by the body mass index (BMI)
BMI 30 and greater is considered obese (patients BMI
41.8)
Obesity can be treated and managed through a
combination of lifestyle changes: healthy dietary
changes, exercise, and behavioral changes. Some
patients choose medications, weight loss plans, or
surgery if the first plan failed.
Associated risks with obesity include stroke,
hypertension, diabetes, heart failure, kidney disease,
metabolic disorder, coronary artery disease, psychiatric
disorders, etc.
Medical Treatment
Patient presented to the ED with intractable nausea and vomiting
with abdominal pain present for about a month

Patient was admitted to the observation unit where her nausea


and vomiting worsened and her abdominal pain was hard to
manage, due to her inability to tolerate oral intake she was
transferred to the GPU

Patient was admitted to F4 and had an MRCP done; it showed


dilated pancreatic ducts

Her pain was controlled with a PCA pump and eventually weaned
off to oxycodone as needed and she was treated with IVF fluids.
She was intermittently tolerating oral intake and was administered
Tigan for nausea control

Was readmitted multiples times for same complaints

Patient was referred to outpatient gastroenterology and was


enrolled in Henry Ford Home Health Care
Diagnosis and Treatment Documentation
4/18/2017: EGD and ERCP were done that showed esophagitis, erosive
gastropathy, prior minor papilla endoscopic sphincterotomy was open, the
pancreatic strictures had resolved, therefore the prior stent was removed
and not replaced), however was sent to the ED due to her pain
4/19/2017: Patient was admitted to I1 observation unit to manage her pain
4/20/2017: Patient could not tolerate oral intake so she was admitted to F4
for further management
4/21/2017: Nutrition Services Consulted for reduced oral intake
Multiple gastroenterology consults were made for evaluation and they
recommended against inpatient procedures given limited utility of
intervention in the past
Patient was re-admitted two weeks later for same problems
5/5/2017: MRCP revealed no acute changes
5/8/2017: Nutrition Services Consulted again regarding nutrition status
5/12/2017: Nutrition Services Follow-Up providing additional
recommendations to promote intake
5/16/2017: Home Health Care was ordered
6/7/2017: Patient followed up with Gastroenterology and another ERCP was
scheduled, pancreatic enzymes were ordered, a referral to a pancreatic
surgeon was made to discuss possible surgical interventions, and an
appointment for GI motility evaluation was made
6/9/2017: Home Health Care Nutrition Consult was acknowledged
Nutrition Assessment:
Client History
General: adequate sleep, sedentary life style, significant weakness
prior to admission prevented patient from grocery shopping and
preparing meals, poor appetite for the past 6 weeks, only consuming
liquids due to symptoms

GI System: denies swallowing issues, however patient had all of teeth


extracted at the end of February, altered GI tract with intractable
nausea and vomiting, constipation

Other: patient has been evaluated by Behavioral Health whom


suspected an opioid use disorder and recommended limited opioid
use; patient has multiple psychiatric disorders, history of attempted
suicide and sexual abuse, and both of patients parents have a history
of mental illness and drug abuse, does not have a strong support system
Nutrition Assessment:
Client History
Medication Purpose Adverse Side Effects Nutrition Implications
Catapres Lowers blood pressure Drowsiness, fatigue, dry No known nutrition
mouth, loss of appetite, implications
constipation, insomnia
Colace Relieves and prevents Bloating, gas, cramping, Risk the loss of normal
constipation diarrhea, bowel function if used
improperly
Lovenox Anticoagulant; helps Nausea, diarrhea, swelling in No known nutrition
prevent blood clots hands/feet, fever implications
Prozac Antidepressant Headache, dizziness, loss of No known nutrition
appetite, nausea, vomiting, implications
diarrhea, dry mouth,
tremors, fatigue
Neurontin Anti-epileptic; Headache, dizziness, No known nutrition
anticonvulsant that memory problems, implications
treats nerve pain or restlessness
seizures
Lamictal Anti-epileptic; Headache, blurred vision, No known nutrition
anticonvulsant that tremor, dry mouth, nausea, implications
treats seizures and can vomiting, diarrhea, insomnia,
delay mood episodes in fatigue, rash
bipolar disorder
Medication Purpose Adverse Side Effects Nutrition Implications
Synthroid Treats hypothyroidism Irregular heart rate, Misused a weight-loss
sweating, insomnia, medication; Tube
vomiting, diarrhea, feeding must be held
appetite changes, one hour before and
weight changes one hour after taken
orally
Mag-Ox Treats acid indigestion, Diarrhea Prescribed if serum
heartburn, or low magnesium levels are
magnesium levels in the low
body
Robaxin Muscle relaxant to treat Slow heart rate, seizure, No known nutrition
pain or injury to skeletal headache, nausea, implications
muscles vomiting, blurred vision,
flushing
Reglan Gut motility stimulator Drowsiness, dizziness, Can treat GERD and
that increases headaches, insomnia, can sometimes be used
contractions in the nausea, vomiting, to prevent
upper digestive tract to diarrhea, frequent nausea/vomiting
speed up stomach urination
emptying
Zofran Prevents nausea and Diarrhea, constipation, Can allow for
vomiting headache, drowsiness improvement in
nutritional status
Protonix Proton pump inhibitor Stomach pain, gas, Treats GERD, can cause
that reduces the nausea, vomiting, bloody or watery
amount of acid diarrhea, fever, diarrhea and it is
produced in the headache, cold advised against using
stomach symptoms anti-diarrheal medicine
unless prescribed
Medication Purpose Adverse Side Effects Nutrition Implications

Glycolax Laxative, increases Bloating, gas, dizziness, Can relieve


water in intestinal tract increased sweating constipation, not
recommended for
bowel obstructions
Seroquel Anti-psychotic used to Dizziness, increased Long-term use can
treat schizophrenia and appetite, weight gain, contribute to weight
bipolar disorder sore throat, dry mouth, gain and elevated lipids
nausea, vomiting,
constipation
Effexor Anti-depressant that Nausea, vomiting, Weight loss or gain have
can also treat anxiety diarrhea, changes in both been observed in
appetite or weight, dry clinical studies, as well
mouth, fast heartbeat, as hypercholesterolemia
tremors, insomnia
Klonopin Anti-epileptic drug to Fatigue, depression, No known nutrition
treat seizures, can also drowsiness, problems implications
be used to treat panic with balance and
disorder coordination
Dilaudid Opioid pain medication Nausea, vomiting, Not recommended in
constipation, patients with small
drowsiness, fatigue, bowel obstructions
sweating, dry mouth,
flushing of skin
Tigan Treats nausea and Blurred vision, diarrhea, Can ultimately improve
vomiting disorientation, dizziness, nutritional status
headache, muscle
cramps
Ambien A sedative used for Fatigue, dry mouth, No known nutrition
those with insomnia nausea, constipation, implications
diarrhea, headache
Nutrition Assessment: Anthropometrics

Anthropometrics
Height: 58
Admission Weight: 125 kg (275 lbs)
BMI: 41.8 Class III Obesity
Ideal body weight: 63.6 kg (140 lbs)
Ideal body weight %: 196%
Usual body weight: 130 kg (287 lbs)
Weight History
131
130
129
128
127
126
125 Weight (kg)
124
123
122
6 kg weight loss in 3 weeks, 4% weight loss
121
Nutrition Assessment:
Food/Nutrition-Related History
Typical Daily Intake: Diet Prescription in Hospital:
Soft consistency foods 6 Small Meals,
including pudding, Mechanical Soft
Gatorade, Diet Ginger Clear Liquid
Ale, mashed potatoes, Full Liquid
ice cream, soup,
popsicles Altered GI function,
Biting/Chewing Difficulty
Previous Diet Therapy:
Was a participant in Estimated Nutritional Needs
weight watchers in 2012 Calories: 1600-1900
Instructed on low-fat diet kcal/kg (25-30 kcal/kg of
ideal body weight)
Protein: 76-89 grams per
day (1.2-1.4 grams/kg of
ideal body weight)
Nutrition Assessment:
Biochemical Data
Lab 4/20/17 5/4/2017 5/10/2017 5/22/2017 Reason

Sodium 139 136 134L 140 Over-hydration,


Ref Range: 135- fluid
145 mmol/L overload/edema,
starvation,
hyperglycemia
Potassium 3.7 4.0 4.0 4.0 WNL
Ref Range:
3.5-5.0 mmol/L

BUN 5L 5L 2L 10 Malnutrition or
Ref Range: malabsorption, over-
10-25 mg/dL hydration

Creatinine 0.63 0.70 0.69 0.69 WNL


Ref Range:
<1.03 mg/dL

Magnesium - 1.9 1.7L - Malabsorption or


Ref Range: low dietary intake,
1.8-2.3 mg/dL hypoparathyroidism,
prolonged diarrhea
Nutrition Assessment:
Biochemical Data
Lab 4/20/17 5/4/2017 5/10/2017 5/22/2017 Reason

Phosphorous - 3.8 - 3.9 WNL


Ref Range:
2.5-4.5
mg/dL
Calcium 8.7 9.3 8.9 9.4 WNL
Ref Range:
8.2-10.2
mg/dL
Glucose 105 89 91 115 WNL
Ref Range:
50-140
mg/dL

Lipase 157H 85H - 52 Pancreatitis


Ref Range: associated
0-60 IU/L inflammation or
trauma
Nutrition Assessment:
Nutrition-Related Physical Findings

Nutrition-Related Physical Findings


Obese
Extracted teeth with receding gums
Increased generalized weakness per
patient report and frequent
hospitalizations
Nutrition Diagnosis
Nutrition Diagnoses
Inadequate protein-energy intake
Biting/chewing difficulty
PES Statements
Inadequate protein-energy intake related to altered GI
function, intractable nausea and vomiting, abdominal pain
as evidenced by intake of only bites of cereal this morning
(emesis following), full liquid diet for approximately 6 weeks
per patient, 10-12 lbs. weight loss in one month (3.5-4%),
significantly decreased energy affecting activities of daily
living
Biting/chewing difficulty related to poor dentition, patient
had all of her teeth removed and has not been able to have
dentures made yet as evidenced by avoiding tough and
difficult to chew foods
Care Level: 3- moderate risk for malnutrition
Malnutrition
Patients Signs and Symptoms of Malnutrition:

Intake less than 75% of estimated nutrient needs for


one month
Moderate to severe inflammation present
Unintended weight loss of 12 pounds (4%) in 3 weeks
Generalized weakness resulting in decline in
activities of daily living

Although malnutrition was never documented during


patients admission, it was stated that she may be acutely
malnourished
Nutrition Intervention
Interventions & Recommendations in the Hospital

Order Ensure Clear 3 times per day


Order 3 Day Calorie Count
Order high protein and calorie nourishments
Order daily multivitamin and continue with home
supplementation of Vitamin D3, B12, and Iron
Monitor tolerance and adequacy of nutrition intake
closely, advance diet as tolerated
Consider alternate route of nutrition if daily vomiting
continues (enteral vs. parenteral)
Nutrition Intervention
Teaching Plan

Small, frequent meals throughout the day


with nutrition supplementation of Ensure Clear as tolerated

Discuss healthier options for soft consistency foods with


adequate protein and calories

Low-Fiber Nutrition Therapy from Nutrition Care Manual to


provide patient with what foods are not easily tolerated in
gastroparesis and provide her with options that she can eat

Low-Fat Nutrition Therapy from Nutrition Care Manual

*Patient is expected to be mostly compliant with diet plan as she


was willing to listen and eager to ask questions, however
socioeconomic constraints may limit healthy options*
Nutrition Monitoring and Evaluation
Initial Admission
4/21/17 Nutrition Services Consult
Diet Order: Mechanical/dental soft, 6 small meals
PES: Inadequate protein-energy intake related to
altered GI function, intractable nausea and vomiting,
abdominal pain as evidenced by intake of only bites
of cereal this morning (emesis following), full liquid diet
for approximately 6 weeks per patient, 10-12 lbs.
weight loss in one month (3.5-4%), significantly
decreased energy affecting activities of daily living
Interventions: Ordered high protein nourishment
preferences- Mighty Shakes, Magic Cups, Multivitamin
Nutrition Monitoring and Evaluation
Second Admission
5/8/17- Nutrition Services Consult
Diet Order: Mechanical/dental soft
PES: Biting/chewing difficulty related to poor dentition,
patient had all of her teeth removed and has not been able
to have dentures made yet as evidenced by avoiding tough
and difficult to chew foods
PES: Inadequate energy intake related to altered GI
function, intractable nausea, vomiting, abdominal pain as
evidenced by intake of less than 75% of estimated energy
requirements for over month, 14 pounds/4.8% weight loss in
one month, significantly decreased energy affecting
activities of daily living
Interventions: Added Magic Cups and high protein broth
three times per day. Recommended diet order change to
Mechanical Soft, 6 Small Meals.
Nutrition Monitoring and Evaluation
Second Admission
5/12/17- Nutrition Services Follow-Up
Diet Order: Full Liquid
PES: Biting/chewing difficulty related to poor dentition,
patient had all of her teeth removed and has not been able
to have dentures made yet as evidenced by avoiding tough
and difficult to chew foods- NO IMPROVEMENT
PES: Inadequate energy intake related to altered GI
function, intractable nausea, vomiting, abdominal pain as
evidenced by intake of less than 75% of estimated energy
requirements for over month, 14 pounds/4.8% weight loss in
one month, significantly decreased energy affecting
activities of daily living- NO IMPROVEMENT
Interventions: Recommended Ensure Clear three times daily
and advance diet as tolerated
Nutrition Monitoring and Evaluation
Home Health Care
Nutrition Consult 6/9/17
Spoke with patient over the phone regarding appetite and
nutrition status at home
Vomiting has subsided from 6 times a day to 3 times
Patient is still without dentures, has plans to get them by the end
of the month
Still consuming soft foods (pudding, mashed potatoes, stovetop
stuffing, rice, soup, popsicles)
Patient is limited on cooking and grocery shopping due to
weakness so she is working with Adult Services to get an aide to
help out at home
Discussed using a home scale to monitor weight status
Discussed importance of taking pancreatic enzymes with meals
once patient receives them
Interventions: discussed low-fiber, low-fat nutrition therapy with
patient and mailed the materials to her house, along with
coupons for Ensure Clear
Monitoring and Evaluation
Parameters to Monitor
Monitor progress of nausea and vomiting, amount of
oral intake consumed, tolerance of full liquid diet to
advance to low fat, low fiber diet, weight changes,
electrolyte imbalances, hydration status, blood
glucose to determine the need to resume Metformin
medication
Monitor progress once pancreatic enzyme
supplementation begins
Reassess patient if Puestow Procedure is performed

Future Needs
Patient is enrolled in Home Health Care and is being
followed by an RD, PT/OT, and Skilled Nursing
Research Articles

1. The Prevalence of Malnutrition and Fat-Soluble


Vitamin Deficiencies in Chronic Pancreatitis
2. Efficacy of pancreatic enzyme replacement
therapy in chronic pancreatitis: systematic review
and meta-analysis
3. Efficacy of dietary fat and food consistency on
gastroparesis symptoms in patients with
gastroparesis
The Prevalence of Malnutrition and Fat-Soluble Vitamin
Deficiencies in Chronic Pancreatitis

Purpose: To examine fat-soluble Results: Half of the patients in the


vitamin levels and malnutrition chronic pancreatitis group were
parameters in patients with overweight/obese. Handgrip
chronic pancreatitis strength, fat stores, and muscle
stores were lower in patients than
Method: Prospective controlled in controls. 14.5% and 24.2% were
cohort study with 128 subjects (62 deficient in Vitamin A and E. 19%
chronic pancreatitis and 66 age- had excess serum Vitamin A
sex-matched controls) levels.
participated. BMI, handgrip Conclusion: Despite the
strength, fat stores, muscle stores, prevalence of
exocrine function, and serum overweight/obesity, patients had
levels of fat-soluble vitamins were lower muscle stores, strength, and
measured. abnormal serum vitamin levels.
Patients would likely benefit from
Vitamin D supplementation

Grade: 2B
Efficacy of pancreatic enzyme replacement therapy
in chronic pancreatitis: systematic review and meta-
analysis
Purpose: to determine the pain. Follow-up studies showed
benefits of pancreatic enzyme that it also was able to increase
replacement therapy in chronic serum nutritional parameters,
pancreatitis improve gastrointestinal
symptoms, and overall quality of
Method: Major databases were life. The higher doses and enteric
searched from 1966 to 2015 coated enzymes showed to be
inclusive. 17 studies were included more effective than low-dose or
and assessed qualitatively. non-coated enzymes.
Quantitative data were
synthesized from 14 studies. Conclusion: Pancreatic enzyme
511 patients with chronic replacement therapy is indicated
pancreatitis were assessed. to treat pancreatic exocrine
insufficiency and malnutrition in
Results: PERT improved coefficient chronic pancreatitis and has
of fat absorption compared with been shown to be improved by
baseline and placebo. It also higher doses and enteric coating
showed to improve nitrogen with administration during food
absorption, reduce fecal fat and and acid suppression
fecal nitrogen, and abdominal
Grade: 2B
Efficacy of dietary fat and food consistency on
gastroparesis symptoms in patients with gastroparesis
Results: The high-fat solid meal
Purpose: to determine the effect of increased overall symptoms among
fat intake and solid vs. liquid meal patients with gastroparesis, whereas
consistency on symptoms in low-fat liquid meals had the least
gastroparesis effect.
Method: Subjects had to have an Conclusion: The rate of gastric
established diagnosis of emptying is affected by multiple
gastroparesis with delayed gastric factors including meal volume,
emptying. Participants were studied calorie content, and meal
on four occasions and received one composition, as well as fiber and fat
of four meals on four different days content. Small frequent meals are
(high fat solid and liquid, and low fat another common recommendation.
solid and liquid meals). A food Symptom severity was the main
frequency questionnaire was given outcome variable. Measuring
to determine the patients usual gastric emptying while recording
nutrient intake. Two other symptoms might help determine if
questionnaires were also given the increased symptoms during fatty
regarding pain and exercise habits. meals and less symptoms during the
Body composition was measured as liquid meals were related to gastric
well. emptying.

Grade: 2B
Additional Diet Recommendations
There is limited research, but adding medium-chain
triglycerides to the diet can be beneficial because
they are absorbed in the jejunum and ileum without
the need for lipase or bile salts (which are both
deficient in patients with chronic pancreatitis)
Reducing fiber has also been shown to be
beneficial in patients with gastroparesis to slow
motility as well as in pancreatitis because fiber can
inhibit lipase activity
Enteral nutrition is not heavily studied in chronic
pancreatitis, however long-term jejunal feedings
may result in weight gain and a reduction in
abdominal pain with minimal complications
Conclusion
There are a variety of pancreas disorders and the
treatment depends on the type and severity of the
disorder

The treatment and management of both gastroparesis


and pancreatitis are multifactorial and it incorporates
analgesics, prokinetic agents, dietary modifications such
as a low fat, low fiber diet with small frequent meals, and
endoscopic or surgical treatment

There is limited evidence on nutrition management in


chronic pancreatitis that is up to date, however these
patients remain at high risk for malnutrition and vitamin
deficiencies due to malabsorption and maldigestion
References
Duggan, S. N., Smyth, N. D., OSullivan, M., Feehan, S.,
Ridgway, P. F., & Conlon, K. C. (2014). The Prevalence of
Malnutrition and Fat-Soluble Vitamin Deficiencies in Chronic
Pancreatitis. Nutrition in Clinical Practice, 29(3), 348-354.
doi:10.1177/0884533614528361
Garca, D. D., Huang, W., Szatmary, P., Bastn-Rey, I.,
Gonzlez-Lpez, J., Prada-Ramallal, G., . . . Nihr Pancreas
Bru Patient Advisory Group. (2016). Pancreatic enzyme
replacement therapy in chronic pancreatitis: Systematic
review and meta-analysis. Pancreatology, 16(3).
doi:10.1016/j.pan.2016.05.317
Homko, C. J., Duffy, F., Friedenberg, F. K., Boden, G., &
Parkman, H. P. (2015). Effect of dietary fat and food
consistency on gastroparesis symptoms in patients with
gastroparesis. Neurogastroenterology & Motility, 27(4), 501-
508. doi:10.1111/nmo.12519
Pancreas Divisum. (n.d.). Retrieved May 28, 2017, from
https://pancreasfoundation.org/patient-
information/ailments-pancreas/pancreas-divisum/
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