Recurrent Pancreatitis in a Patient With Abnormal Pancreaticobiliary Junction: Case Report

Abstract

Introduction: 22-year-old female being followed for idiopathic recurrent pancreatitis with negative genetic testing, HIDA scan, and image findings status post elective cholecystectomy was found to have pancreaticobiliary junction anomaly with pancreatic duct emanating from common bile duct. Case Description: Patient was seen in July 2017 for chronic abdominal pain and idiopathic pancreatitis with negative HIDA scan and equivocal CT and MRI findings. Genetic workup of PRSSI, CFTR, and SPINK were negative. No family history of pancreatitis. No alcohol consumption. EUS done in July 2017 showed hyperechoic material consistent with sludge in the gallbladder along with thickened gall bladder walls. Pancreatic duct had an irregular contour along with parenchymal abnormalities consistent of hyperechoic foci and the pancreatic duct appeared to disappear into the common bile dict. Patient underwent cholecystectomy in December 2017 without much relief. Patient was again seen in May 2018 at which EUS was again performed along with ERCP. ERCP showed a filling defect on the pancreatogram that consisted of a common channel whereby the pancreatic duct emanates from the common bile duct approximately 2 cm proximal to the sphincter of Oddi (figure 1). A biliary sphincterotomy was performed and temporary stent was placed into the common bile duct. This has so far controlled the patients' symptoms. Discussion: Abnormal pancreaticobiliary junction (APBJ) is a rare disorder that has been associated with high incidence of gallbladder cancer especially in Asian population. This congenital disorder causes the junction of biliary and pancreatic duct to be located outside the duodenal wall forming a common channel. Since the junction doesn't involve the duodenal wall, it's functions is not under the influence of sphincter of Oddi causing pancreatic biliary reflux (PBR). This reflux is associated with likely hyperplasia and carcinoma of the biliary system. APBJ is almost always seen in patients with choledochal cyst. There have been studies that have shown acute and chronic pancreatitis in setting of choledochal cyst but to our knowledge pancreatitis without choledochal cyst in a setting of APBJ has not been described. Clinician and researchers should be aware of APBJ with pancreatic duct emanating from common bile duct as a cause of recurrent pancreatitis.1430.tif Figure 1: A filling defect as seen on the pancreatogram that consist of a common channel whereby the pancreatic duct emanates from the common bile duct approximately 2 cm proximal to the sphincter of Oddi.