57-year-old patient with repeated hospital admissions for epigastralgia accompanied by minimal elevations of amylase. The patient was diagnosed with prostatic adenoma. He reported epigastric pain and abdominal distension during meals that forced him to stop eating. On three occasions the patient attended the emergency department. Only a slight elevation of amylase (155 IU, normal < 100) was observed. In an attempt to reach a diagnosis, a trancutaneous abdominal ultrasound, gastroscopy, colonoscopy and abdominal CT scan were performed. All tests were normal. Finally, a magnetic resonance cholangiopancreatography (MRCP) was performed. Only the common bile duct and Wirsung's duodenum were found to lead separately into the duodenal wall. Initially it was interpreted as a variant of normality that can occur in up to 24% of normal subjects (1). However, given the disabling symptoms (the patient reported epigastralgia with almost every meal), it was suggested that an endoscopic retrograde cholangiopancreatography (ERCP) be performed.

There was a history of allergy to iodinated contrasts, so glucocorticoid prophylaxis was performed. On endoscopic imaging the papilla had a flaccid appearance. The bile duct was deeply cannulated and a 0.025-inch guidewire was introduced to ensure access to the common bile duct. The introduction of contrast for cholangiopancreatography was performed from the same papillary orifice. During injection the papilla showed a distension visible on the endoscopic image and appeared as a cystic structure on cholangiography. The Wirsung was also drawn during the contrast injection but emptied immediately and was therefore not reflected on the radiographs. The diagnosis of choledochococele was made and it was sectioned by biliary sphincterotomy. The patient had no complications from the endoscopic intervention and the pain during swallowing has not reappeared after two years of follow-up.