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INTRODUCTION: Choledochal cysts are a rare congenital cystic dilation of the biliary tract and occur commonly in female infants and young children. Although rare in Western countries, choledochal cysts are more common in East Asian countries with Type II cysts accounting for only 2% of reported cases. We present an interesting case of a Type II choledochal cyst in a patient with chronic pancreatitis. CASE DESCRIPTION/METHODS: A 56 year old male presented with abdominal pain associated with nausea and non-bloody emesis. He also had reduced appetite, dark urine, and a 10 pound weight loss over several months. Physical examination revealed scleral icterus and epigastric abdominal tenderness. Laboratory investigations revealed mild leukocytosis (11.1), elevated total bilirubin (8.6), aspartate aminotransferase (77), alanine aminotransferase (128), and alkaline phosphatase (556). A CT with intravenous contrast (Figure 1) demonstrated coarse calcifications within the pancreas, a large cystic lesion within the head of the pancreas with marked pancreatic ductal dilation, atrophy, and intraductal calcifications. Gallbladder distension with sludge and upstream biliary dilatation was also noted. Endosonographic images (Figure 2) revealed an anechoic cystic lesion in the head of the pancreas with compression of the common bile duct (CBD). Fine needle aspiration was performed with aspirated fluid highly suggestive of bile. A cholangiogram confirmed the presence of an intrapancreatic cystic cavity in direct communication with the distal CBD in a diverticular configuration suggestive of a Type II choledochal cyst with narrowing of the adjacent CBD. A pancreatic sphincterotomy followed by pancreas stone lithotripsy and stone extraction was performed. A biliary stent was placed into the CBD. The patient tolerated the procedure well and was scheduled for multidisciplinary discussion pending brush cytology. DISCUSSION: Choledochal cysts are congenital anomalies which results in cystic dilation of the biliary tree. Adults are more likely to present with biliary or pancreatic symptoms whereas children present with an abdominal mass and jaundice. Malignancy is associated with Type I and IV cysts while Types II, III, and V cysts have minimal neoplastic risk. Treatment is based on the cyst type. Diverticulectomy of Type II choledochal cyst followed by primary CBD closure at the diverticulum neck is usually sufficient. A multidisciplinary approach may be warranted based on patient clinical status and co-morbidities.

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