Biliopancreatic reflux via anomalous pancreaticobiliary junction

A PREVIOUSLY HEALTHY 32-YEAR-OLD WOMAN experienced an attack of mild acute pancreatitis manifested by right upper quadrant abdominal pain and hyperamylasemia (1676 IU/L; normal range, 50 to 240 IU/L). The patient had no history of excessive alcohol intake or jaundice. Conservative treatment improved the acute pancreatitis. Endoscopic retrograde cholangiopancreatography showed a long (11 mm) common channel, a dilated (48 mm) extrahepatic bile duct with gallstones, and nondilated normal pancreatic ducts (Fig 1). These findings represented anomalous pancreaticobiliary junction (APBJ) associated with choledochal cyst (Todani’s type I).1 Drip infusion cholangiography (DIC)-multidetector row computed tomography (MDCT) was performed using Aquilion (Toshiba Medical System, Tokyo, Japan) with four high-resolution detectors. After intravenous injection of a 100-mLdose of iotroxate meglumine (Biliscopin DIC 50; ScheringAG, Berlin, Germany),maximum intensity projection (MIP) images obtained by DIC-MDCT showed a long common channel, a dilated extrahepatic bile duct, and a proximalmain pancreatic duct (of the pancreatic head) (Fig 2). At 30minutes after ingestion of 4 g of dried egg yolk (Molyork; Toho Chemical Co, Osaka, Japan), DIC-MDCT demonstrated the main pancreatic duct more distally (Fig 3). Axial images revealed yolk-induced contraction of the nonopacified gallbladder. This patient underwent excision of the extrahepatic bile duct and gallbladder followed by