Alexander Schlachterman, MD, from the Division of Gastroenterology, Hepatology and Nutrition at the University of Florida in Gainesville, Florida, USA shares this video case, “Type III choledochal cyst and anomalous pancreatobiliary junction.”

A 34-year-old male with 2 episodes of acute recurrent pancreatitis was referred for endoscopic retrograde cholangiopancreatography (ERCP) to further evaluate 5 cm intraduodenal dilation of the distal common bile duct suggestive or Type III choledochocal cyst which was noted on magnetic resonance cholangiopancreatography (MRCP).

At ERCP, a large subepithelial bulge was found in the anticipated location of the major papilla. Careful observation failed to reveal the drainage opening of the cyst. The cystic lesion was unroofed with a snare and the orifice of the pancreatobiliary system was identified. Contrast injection into the opening revealed an anomalous pancreatobiliary junction (APBJ). The pancreatogram and cholangiogram were otherwise normal without any evidence of Type I choledochal cyst. A sphincterotomy was done and biliary and pancreatic plastic stents were placed. Two weeks later the stents were removed. The patient was referred for cholecystectomy due to the increased risk of gallbladder cancer associated with APBJ in the absence of Type I choledochal cyst.

This case demonstrates the technique of unroofing Type III choledochal cyst in order to locate the pancreatobiliary system drainage orifice. Identification of the drainage orifice is vital for diagnosis and treatment of a type III choledochal cyst with anomalous pancreato-biliary junction. This video encompasses the technique for a challenging case.

This patient had unusual association of Type III choledochal cyst and APBJ as a cause of his acute recurrent pancreatitis. Other endoscopists should be aware of this condition for future diagnostic purposes as well as treatment options for cases with this similar diagnostic dilemma.

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