S1689 Anomalous Biliary-pancreatic Junction: A Case of Recurrent Pancreatitis and Implicit Bias

Abstract

Introduction: Implicit bias is defined as the attitudes or stereotypes that unconsciously affect our understanding, actions, and decisions. Physicians must make a concerted attempt not to fall prey to implicit bias as this can lead to differences in the quality of care between patients. We describe a case of implicit bias secondary to a diagnosis of anomalous biliary pancreatic junction (ABPJ). Case Description/Methods: A 50-year-old Hispanic woman with an extensive psychiatric history, polysubstance abuse, and recurrent pancreatitis presented with abdominal pain. Given her history, the etiology of recurrent pancreatitis was deemed to be due to polysubstance abuse. CT abdomen showed a dilated common bile duct, dilated pancreatic duct, and pancreatic calcifications consistent with a history of chronic pancreatitis. Review of previous medical records showed that a prior MRCP had revealed duplication of the biliary ductal system. The medial duct draining the right lobe of the liver, anastomosed with the pancreatic duct to form a common channel that opened into the duodenum. The lateral duct drained the left lobe of the liver and opened it into the duodenum through a separate papilla. Gastroenterology was consulted and a diagnosis of ABPJ was made. Consequently, the patient's episodes of pancreatitis were thought to be secondary to ABPJ. Patient then underwent an ERCP with pancreatic sphincterotomy and stent placement, leading to significant symptom resolution. Discussion: ABPJ is a congenital malformation where the biliary and the pancreatic ducts join outside the wall of the duodenum. Incidence is estimated to be 1.5 – 3.2 % among all patients that undergo an ERCP. Since the function of the duodenal papilla does not traverse the length of the common duct, regurgitation of pancreatic and biliary secretions occurs. In most cases, the pressure in the pancreatic duct is higher, resulting in the reflux of pancreatic juice into the biliary tract and subsequent development of biliary tract malignancy. In a rare minority of cases, bile can reflux into the pancreatic ductal system, causing recurrent pancreatitis. ABPJ is a rare and under-recognized cause of recurrent pancreatitis in the adult population. Often, the diagnosis of ABPJ is overshadowed by the treating physician’s implicit bias due to patient factors such as ethnicity, age, past medical history, etc. A high index of suspicion is required to make an accurate diagnosis leading to prompt intervention, thus avoiding delay in care and associated morbidity.Figure 1.: CT scan showing collection in Gall Bladder fossa.