AN UNUSUAL VARIANT OF ANOMALOUS PANCREATICOBILIARY JUNCTION

Objectives: A 27-year-old African American female presented to the Emergency Department with an acute onset of severe epigastric abdominal pain and nausea. Laboratory studies proved unremarkable. CT scan of the abdomen and pelvis with intravenous contrast demonstrated intrahepatic and extrahepatic biliary ductal dilation with possible stones within the distal common bile duct. The patient was discharged with a general surgery follow-up appointment. Laparoscopic cholecystectomy with intraoperative cholangiography was performed 3 weeks later due to concern for choledocholithiasis. The intraoperative cholangiogram showed multiple abnormalities, concerning for primary sclerosing cholangitis, ascending cholangitis, primary biliary cholangitis, and idiopathic cholangitis. MRCP further identified a complex anomalous pancreaticobiliary junction and cystic lesion in the region of the pancreatic head, suggesting a choledochal cyst or a hypersecreting intraductal papillary mucinous tumor of the bile duct with concurrent primary sclerosing cholangitis. Subsequent ERCP showed normal-appearing biliary and pancreatic mucosa with at least three tributaries directly from the pancreas entering the bile duct at various levels, as well as an ansa orientation to the pancreatic duct. Biopsies taken from the pancreaticobiliary mucosa were benign. Patient is recommended to have annual MRCP and MRI to assess for any findings concerning for neoplasm given the anomalous pancreaticobiliary junction.

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