Concurrent Choledochocele and Wirsungocele Presenting With Recurrent Acute Pancreatitis in a 21-Year-Old Male

Choledochal cysts, including choledochocele (Todani type III), and wirsungocele-cystic dilatation of the terminal main pancreatic duct are uncommon; their coexistence is exceptional and may predispose to pancreatitis. We report the case of a 21-year-old man with recurrent acute pancreatitis who presented with epigastric pain radiating to the back and vomiting. Serum lipase was 611 U/L (~13× the upper limit of normal), with mild cholestatic enzyme elevation. Ultrasound showed acalculous cholecystitis and a dilated common bile duct. A CT scan demonstrated grade C pancreatitis, and magnetic resonance cholangiopancreatography (MRCP) found a biliary tract dilatation with a saccular ectasia at the biliopancreatic junction. Endoscopic ultrasonography (EUS) identified a 3-mm intra-ampullary cyst of the main pancreatic duct (wirsungocele) and a choledochocele. During laparoscopic cholecystectomy, intraoperative endoscopic retrograde cholangiopancreatography (ERCP) with infundibulotomy and biliary sphincterotomy exposed both orifices; balloon sweeping retrieved debris. No stent was placed. The postoperative course was uneventful, symptoms resolved, and liver enzymes normalized at one-month follow-up. This case highlights that dual duct anomalies should be considered in young patients with recurrent "idiopathic" pancreatitis. EUS and ERCP can outperform MRCP for defining small intra-ampullary cysts and enable targeted endoscopic therapy. Given the malignancy risk associated with choledochal cysts, ongoing surveillance is advised.