An Uncommon Cause of Recurrent Pancreatitis

Abstract

Introduction: Biliary cysts are important structural anomalies of the biliary tract. While normally found in the pediatric population, 20% of these rare dilations of the biliary tree are found in adults and account for a variety of biliary and pancreatic complications. Case Presentation: A 33-year-old white male with a 3-year history of recurrent pancreatitis presented to our institution with 2 weeks of light stools, dark urine, weight loss, and fatigue. Three days prior to admission, he developed icterus and nausea. He had a cholecystectomy 3 years prior. He took no medications. He drank alcohol socially. There was no family history of gastrointestinal disease. On physical examination, he was afebrile with stable vital signs. Scleral icterus was present. He had left abdominal tenderness. No hepatosplenomegaly was appreciated. He was jaundiced. His initial laboratory evaluation was notable for a total bilirubin of 11.1, direct bilirubin of 8.4, alkaline phosphatase of 346, aspartate aminotransferase of 105, and alanine aminotransferase of 210. Lipase was 29. A serum chemistry and complete blood count were normal. A magnetic retrograde cholangiopancreatography was performed which showed a cystic dilation measuring 2.7 x 2.7 cm in the head of pancreas that was inseparable from the common bile duct and the pancreatic duct. The common bile duct was 1.7 cm dilated. Intrahepatic duct dilation was present. The pancreatic duct was not dilated. An endoscopic retrograde cholangiopancreatography confirmed bulging of the major papilla with cystic dilation of the intra-duodenal portion of the bile duct where the common bile duct and the pancreatic duct drained into the cyst consistent with a type IIIA choledococele. The pancreatic duct was irregular and tortuous in the head of the concerning for chronic pancreatitis. A biliary sphincterotomy was performed and a biliary stent was placed. A pancreatic duct stent was placed. Liver function tests did improve with this intervention and the stents were removed 1 month later. The cholangiogram was normal at that time. Discussion: Biliary cysts, while rare, do cause chronic biliary and pancreatic pathology including cholelithiasis, biliary strictures, acute and chronic pancreatitis, cholangiocarcinoma, secondary biliary cirrhosis, and cholangitis. This case illustrates that importance of keeping in mind rarely seen structural anomalies that can cause biliary and pancreatic disease and can have long term consequences such as cirrhosis, recurrent cholangitis, chronic pancreatitis, and most significantly carcinoma.