Dual Ampullary Orifices: A Forgotten Embryologic Anomaly in Modern ERCP

Bile duct and pancreatic duct join as a single orifice at ampulla of Vater. Anomalous rotation or recanalization of hepatopancreatic ducts during embryogenesis can lead to anatomical variations of ampulla of Vater. One such anatomical variation is double major papilla with dual ampullary orifices for bile and pancreatic duct, the incidence of which is exceedingly rare. Identification and early recognition of such variations before initiating cannulation can prevent inadvertent pancreatic duct cannulation. We report a case of 78-year-old man with chronic calcific pancreatitis with choledocholithiasis, found to have dual ampullary orifices. Selective cannulation was performed for each duct followed by stenting without any complications. This case emphasizes that knowledge and awareness of such rare ampullary variations can prevent inadvertent pancreatic duct cannulation.