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Duplication of the extrahepatic bile duct with anomalous union of the pancreaticobiliary ductal system revealed by MR cholangiopancreatography

¹ Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 388-1 Pungnap-2dong, Songpa-gu, 138-736 Seoul, Korea, ² Weill Medical College of Cornell University, 1300 York Avenue, New York, NY 10021, USA

View larger version (282K): [in this window] [in a new window]   Figure 1. A 72-year-old women with right upper quadrant pain, jaundice and generalized pruritus. (a) Contrast-enhanced CT image during the portal venous phase shows diffuse dilatation of the intrahepatic bile ducts and an enhancing wall thickening of the hilum (black arrow), representing hilar cholangiocarcinoma. (b) Initial endoscopic retrograde cholangiopancreatography (ERCP) image demonstrates duplication of the extrahepatic bile ducts with early junction (black arrow) between the medial, accessory bile duct and the main pancreatic duct (arrowheads) and subsequent formation of a long common channel (curved arrow). Proximal communication of both extrahepatic bile ducts (white thick arrow) with irregular luminal narrowing, representing cholangiocarcinoma, is also noted. Note that there is also communication between the accessory extrahepatic bile duct and a branch pancreatic duct (white thin arrow). (c) Initial ERCP image shows distal union (white arrow) of both extrahepatic bile ducts to form a short common bile duct. (d) Oblique coronal, thick-slab maximum intensity projection (MIP) MR cholangiopancreatography image from a free-breathing navigator triggered T2 weighted turbo spin-echo sequence with prospective acquisition correction (repetition time (TR)/echo time (TE) 5515/671; slice thickness 50 mm) demonstrates the absence of proximal communication between both extrahepatic biliary ducts. The abnormal arrangement of the pancreaticobiliary ductal union (curved arrow) and the long common channel (black arrow) are also noted. ) (e) Oblique coronal, thin-slab MIP MR cholangiopancreatography image from a free-breathing navigator triggered T2 weighted turbo spin-echo sequence with prospective acquisition correction (TR/TE 5515/671; slice thickness 5 mm) demonstrates better visualization of both proximal extrahepatic bile ducts, including the absence of communication at the intersection (white arrow). Note the distal communication and subsequent formation of a short common bile duct (black arrow). (f) Illustration shows a simplified representation of the anatomical anomaly of the biliary and pancreatic duct systems of the present case. (g) Follow-up ERCP image with insertion of two endoscopic nasobiliary drainage tubes (white arrow) shows clear separation of both extrahepatic bile ducts. (h) Axial contrast-enhanced CT scan caudal to (a) shows two extrahepatic bile ducts with enhancing bile duct wall thickening (arrows).

View larger version (19K): [in this window] [in a new window]   Figure 2. Classification of double extrahepatic bile duct. Modified classification from Saito et al[9] and our new proposal of a fifth configuration type characterized by single drainage of two extrahepatic bile ducts. Type Va includes single drainage without any communication between two extrahepatic bile ducts, and Type Vb includes single drainage with one or more communication channels.