1329 Choledochocele: An Unlikely Culprit of Acute Relapsing Pancreatitis

Abstract

INTRODUCTION: Choledochocele, a type III biliary cyst representing 1-5% of all biliary cysts, is a congenital or acquired cystic dilatation of the intraduodenal bile duct more commonly seen in patients of Asian descent. Patients are usually asymptomatic, but can occasionally present with abdominal pain, jaundice, and a palpable abdominal mass; with malignancy less frequently seen than in other types of biliary cysts. Acute, relapsing pancreatitis is an uncommon presentation. We present a case of recurrent pancreatitis secondary to a choledochocele. CASE DESCRIPTION/METHODS: An 84-year-old woman with a history of DM, HTN, and recurrent gallstone pancreatitis s/p cholecystectomy 2 weeks prior presented with generalized abdominal pain for 1 day. She was febrile to 100.2, with tenderness to palpation of the epigastrium. Lipase was elevated to 1388. CT Abdomen/Pelvis was remarkable for mild common bile duct (CBD) dilation with bulging into the ampulla, a cystic structure in the uncinate process measuring 2.1 cm, and edematous changes in the peripancreatic space around the head and uncinate; consistent with pancreatitis. An MRCP was obtained, and showed no evidence of choledocholithiasis, dynamic bulbous dilatation of the distal CBD at the ampulla of unclear etiology, and interval enlargement of a 2.1 cm simple-appearing pancreatic uncinate cyst. She underwent EUS, which was significant for a choledochocele; followed by ERCP with sphincterotomy and unroofing of the choledochocele with a needle knife, as well as pancreatic duct (PD) stent placement. She was then discharged with follow-up but returned 6 days later, with progressively worsening RUQ pain with nausea and vomiting. Imaging revealed a 2.8 cm peripancreatic fluid collection associated with pancreatic stranding and PD stent dislodgement. She had EUS and FNA of the pancreatic cyst, which showed infected pancreatic necrosis. She improved with Vancomycin and was soon discharged home with outpatient follow-up. DISCUSSION: Choledochocele is an uncommon cause of acute, relapsing pancreatitis, which can cause significant pancreatic pathology over time. If the cyst becomes symptomatic, treatment is required. Since first described by J Siegel in 1981, first-line management has involved sphincterotomy with unroofing. In cases of large >3 cm cysts, or cysts that did not respond to endoscopic management, surgery must be considered.