Multiple cancers in the extrahepatic biliary tree are relatively rare. Many such cases are a double cancer of the common bile duct and the gallbladder. We report a case of a double primary cancer that occurred synchronously at the hilum of the extrahepatic duct and the ampulla of Vater with a review of the relevant literature. A 57-year-old man was admitted to our institution after a 15 day of painless jaundice and a urine color change. Ultrasonography showed a dilation of both intrahepatic ducts. Upper endoscopy revealed a protruding ulcerative mass at the ampulla of Vater and endoscopic retrograde cholangiography showed a dilated common bile duct and a mildly dilatated pancreatic duct, but both intrahepatic bile ducts were not visualized. An upper abdominal CT scan showed a dilation of both intrahepatic bile ducts and an infiltrating mass at the bifurcation area. Magnetic resonance cholangiopanreatography showed narrowing bile duct lumen that was obstructed by the tumor at the hepatic duct bifurcation, which dilated both intrahepatic ducts. A histological examination of the ampulla of Vater revealed a well differentiated adenocarcinoma of the ampulla of Vater. The final diagnosis was a synchronous double cancer of Klatskin's tumor and an adenocarcinoma of the ampulla of Vater.
Adenocarcinoma* ; Ampulla of Vater ; Bile Ducts ; Bile Ducts, Intrahepatic ; Biliary Tract ; Cholangiography ; Common Bile Duct ; Diagnosis ; Endoscopy ; Gallbladder ; Hepatic Duct, Common ; Humans ; Jaundice ; Klatskin's Tumor* ; Middle Aged ; Pancreatic Ducts ; Tomography, X-Ray Computed ; Ulcer ; Ultrasonography

In the diagnosis of bile duct carcinoma, oral or intravenous cholangiography is of no air in the majority ofpatients with bile duct carcinoma who are jaundiced. Recently ultrasonography and CT are widely used for evalutionof biliary disease, but direct visualizing methods of the biliary tract by ERCP and PTC gives more detailed information and exact localization of the lesion. ERCP is less invasive and dangerous and has some more advantages than PTC. We analyzed 33 cases of confirmed extrahepatic bile duct caracinoma who were performed ERCP. The resultswere as follows; 1. The 7th decade was the predilection age, and the radio of male to female was 3.:1. 2. Thelocations of extrahepatic bile duct carcinomas were common bile duct in 45.5%, common hepatic duct in 27.3%,junction of cystic duct and widely extended in 12.1% respectively and junction of hepatic duct in 3.05 in order offrequency. 3. ERCP finding of extrahepatic bile duct carcinomas revealed complete obstruction of bile duct in mostcases, and irregular margined protuberant type was more common than smooth margined constricted type atobstruction site. 4. ERCP finding according to the location of lesion showed that protuberant type was relativelyfrequent in common bile duct and constircted type in common hepatic duct respectively.
Bile Ducts ; Bile Ducts, Extrahepatic ; Biliary Tract ; Cholangiography ; Cholangiopancreatography, Endoscopic Retrograde ; Common Bile Duct ; Cystic Duct ; Diagnosis ; Female ; Hepatic Duct, Common ; Humans ; Male ; Ultrasonography

BACKGROUND/AIMS: The biliary tract often shows various morphologic abnormalities. Thus various anomalies and variations of the cystic duct have been extensively studied via cadeveric or intraoperative dissections and operative cholangiograms. The knowledge of the junction of cystic and common hepatic duct is essential for endoscopic management of biliary tract disease. But no large series identifying this critical cystico-hepatic junction(CHJ) by duodenoscopy has been reported. METHODS: To know the anomaly and variant of CHJ and to evaluate its clinical significence, we retrospectively reviewed 434 cases of endoscopic retrograde cholangiography performed at Korea University Hospital from 1992 through 1993. The CHJ was categorized as lateral or medial only for unequivocal angulation in that direction, and spiral when there is overlap of the CHJ with the bile duct in the posteroanterior view. The CHJ was further modified as parallel if the course of the two ducts was closely adherent for 1 cm or more. In addition to identifying the radial takeoff, the level of the CHJ along the length of the extrahepatic biliary tree was determined. The distance from the ampulla to the junction was divided by the distance from the ampulla to the bifurcation and expressed as proximal, middle, distal, respectively. RESULTS: The level of CHJ was mainly middle in 68.4% followed by distal in 16.4%, prximal in 15.2%. The radial orientation of CHJ was mainly lateral in 51.6%, followed by spiral in 32.3%, medial in 16.1%. The cystic duct runs parallely in 11.5%, mainly in the distally inserted, medially oriented cystic duct. The incidence of abnormalous CHJ was 5 case(1.2%), which included 1 case of cystic duct entering the right hepatic duct, 3 case of cystic duct entering at the junction of both extrahepatic duct(trifurcation), and 1 case of accessory hepatic duct entering cystic duct. The most common biliary disease by ERCP was gallbladder stone(25.5%), followed by common bile duct stone(19.5%), intrahepatic duct stone(7.2%), cystic duct obstruction(4.5%), cystic duct stone(2.9%), and others(bile duct cancer, gallbladder cancer, Mirizzi's syndrome). According to the level of the CHJ, there were low incidence of gallbladder stone in distal CHJ, low incidence of common bile duct stone in proximal CHJ and high incidence of Mirrizi's syndrome and gallbladder cancer in distal CHJ. There were no difference in the incidence of biliary disease according to the radial orientation and course of the CHJ. Practically, during therapeutic ERCP there were some tdchnical difficulties in extraction of biliary stone or selective bile duct cannulation in the presence of distally inserted, parallel course of the cystic duct. CONCLUSIONS: The anatomy of the CHJ by ERCP is more variable than that of previous surgical and autopsy reports and the endoscopist should be aware of this variants for safe and effective intervention in bile duct disease.
Autopsy ; Bile Duct Diseases ; Bile Ducts ; Biliary Tract ; Biliary Tract Diseases ; Catheterization ; Cholangiography* ; Cholangiopancreatography, Endoscopic Retrograde ; Common Bile Duct ; Cystic Duct ; Duodenoscopy ; Gallbladder ; Gallbladder Neoplasms ; Hepatic Duct, Common ; Incidence ; Korea ; Retrospective Studies

PURPOSE: To evaluate the relative image qualities obtained at magnetic resonance cholangiopancreatography (MRCP) turbo spin-echo (SSTSE) sequence and the three-dimensional turbo spin-echo (3D TSE) sequence with the sensitivity encoding (SENSE) technique. MATERIALS AND METHODS: Forty patients with suspected hepatic and extrahepatic diseases underwent MRCP using the SSTSE sequence and the 3D TSE sequence with the SENSE technique. Three radiologists scored and compared the quality of images of anatomic structures in the hepatopancreatic biliary system, and then directly compared the quality of the images obtained using the two sequences in each set of cases. RESULTS: For visualization of the intrahepatic bile duct, the cystic duct, the common bile duct, and the pancreatic duct, MRCP images obtained using the 3D TSE sequence with the SENSE technique were better than those obtained using the SSTSE sequence, though for the intrahepatic bile duct and common bile duct only, were these differences statistically significant (p<0.05). Quality was best for images of the common bile duct (87.5% for SSTSE and 97.5 % for 3D TSE with the SENSE technique). For the pancreatic and cystic duct, however, 52.5% and 10% of SSTSE images, respectively, and 57.5% and 32.5% of 3D TSE images, respectively, provided optimal image quality. In direct comparison, 3D TSE images obtained using the SENSE technique were better in 27 cases (67.5%), both images were equivocal in five cases (12.5%), and SSTSE images were better in eight cases (20%). These differences were statistically significant (p<0.05). CONCLUSION: For the visualization of anatomic structures in the hepatopancreatic biliary system, the 3D TSE sequence with the SENSE technique was better than the SSTSE sequence. For evaluation of the pancreatic and cystic duct, however, both techniques have their limitations and require further development.
Bile Ducts ; Bile Ducts, Intrahepatic ; Biliary Tract ; Cholangiopancreatography, Magnetic Resonance ; Common Bile Duct ; Cystic Duct ; Humans ; Pancreatic Ducts

Biliary adenoma is rarely found in the biliary tract, and there are currently few reported cases of tubular adenoma. Biliary adenoma most often occurs on the duodenal ampulla and the next most common site is on the common bile duct. Because the clinical signs, symptoms and the laboratory findings of these lesions may be similar to malignant biliary diseases, it is difficult to differentiate benign biliary adenoma from malignancy. Therefore, the diagnosis of these tumors tends to be delayed and physicians usually make the pathologic confirmation after a surgical operation. We experienced a case of the simultaneous occurrence of tubular adenoma of the common hepatic duct and gallbladder carcinoma, and all this was diagnosed and treated with common hepatic duct resection and a Roux-en-Y hepaticojejunostomy operation. To the best of our knowledge, this is the first report of biliary tubular adenoma accompanied with gallbladder carcinoma arising from tubulovillous adenoma.
Adenoma ; Biliary Tract ; Common Bile Duct ; Gallbladder ; Hepatic Duct, Common

PURPOSE: To determine relative image qualities and to evaluate their ability to visualize biliary trees and pancreatic ducts, we compared the breath-hold fast spin echo (FSE) and respiratory triggered FSE technique in magnetic resonance cholangiopancreatography (MRCP). MATERIALS AND METHODS: Forty-seven patients with suspected of hepatic disease but no pancreatic or biliary ductal dilatation, as determined by other imaging techniques('group of pathologic pancreatobiliary tree') underwent MRCP. Heavily T2-weighted FSE coronal images were obtained by both breath-hold and respiratory triggered techniques. These two images were 3D-reconstructed using a maximal intensity projection algorithm. Three radiologists scored the image qualities of anatomic structures in each set of image, then directly compared the image quality of the images obtained by the two techniques. RESULTS: For the visualization of common hepatic ducts and common bile dvcts, FSE MRCP images obtained using the respiratory-triggered technique were triggered technique were significantly better than those obtained using the breath-hold technique (P<0.05). Fifty-nine to 88% of breath-hold images of the biliary tree and 63-95% of respiratory triggered images were optimal. For the pancreatic duct, however, 24% of breath-hold images and 15% of respiratory-triggered images provided optimal image quality. In direct comparison, respiratory triggered images were better in 25 cases (52.1%), both images were comparable in 12 cases (25.0%), and in 11 cases (22.9%), breath-hold images were better. These differences were statistically significant (p<0.05). CONCLUSION: For the vizualization of extrahepatic bile ducts, the respiratory triggered FSE sequence was better than the breath-hold sequence; for the evaluation of both a non-dilated and dilated pancreatobiliary system, however, both techniques need further development.
Bile ; Bile Ducts, Extrahepatic ; Biliary Tract ; Cholangiopancreatography, Magnetic Resonance ; Dilatation ; Hepatic Duct, Common ; Humans ; Pancreatic Ducts

Biliary Papillomatosis is an extremely rare pathologic entity. Only about 40 cases of intrahepatic or diffuse intra- and extrahepatic papillomatosis have been described since the first report in 1959 by Caroli. Although this is a histologically benign lesion, its course is unfavaurable because of its tendency to extend to the entire biliary tract, high recurrence rate following local excision and the probability of progression to malignancy. We described herein a case of biliary papillomatosis associated with diffuse bile duct dilatation. The patient, a 59-year-old male, was admitted to our hospital because of right upper abdominal pain and weight loss. Cholangiogram revealed multiple round filling defects in common hepatic duct with intrahepatic bile duct dilatation. The patient underwent Whipple's operation with right lobectomy. Grossly, multiple small pin-head sized polypoid masses were seen in common bile duct, common hepatic duct and right intrahepatic duct. Microscapically, papillary epithelial hyperplasia with moderate cellular atypia was seen and there was no evidence of stromal invasion. He is healthy with a follow-up for 7 months.
Abdominal Pain ; Bile Ducts ; Bile Ducts, Intrahepatic ; Biliary Tract ; Common Bile Duct ; Dilatation ; Follow-Up Studies ; Hepatic Duct, Common ; Humans ; Hyperplasia ; Male ; Middle Aged ; Papilloma* ; Recurrence ; Weight Loss

PURPOSE: The purpose of this study is to evaluate that sequential CT scans after oral contrast ingestion can show morphological and functional status of the biliary tree, especially for the gallbladder and assess whether the CT scans demonstrate other radiological informations than conventional oral cholecystography. MATERIALS AND METHODS: Thirty volunteers in third decades and eight patients with hepatobiliary disease were included for the study. CT scans were obtained 3, 6, 9, 12 hours after oral contrast ingestion and thirty minutes after fat meal in thiry volunteers. Conventional oral cholecystography was also obtained in all volunteers at 12 hours after oral contrast ingestion and after fat meal. We evaluate opacification of gallbladder, biliary tree, and duodenum by contrast media on CT scans and attenuation values of gallbladder, common hepatic duct and common bile duct in each artatomic area on CT and its sequential change. CT scans were performed 6 hours after oral contrast ingestion in eight patients with hepatobiliary disease. And gallbladder function was evaluated by opacification of gallbladder by contrast media in all patients. RESULTS: In thirty volunteers, opacified gallbladder by contrast media was seen in all cases in all sequential periods of time on CT scans, but in 22 cases on conventional oral cholecystography. Contrast-filled intrahepatic ducts were demonstrated in 3 cases at 3 hours after oral contrast ingestion and 11 cases at 6 hours and were not seen thereafter. Contrast-filled common hepatic duct was noted in 28, 18 and 4 cases respectively at 3, 6 and 9 hours after oral contrast ingestion and the CT attenuation values of common hepatic ducts had become progressively decreased. Contrast-filled common bile duct was noted in 28, 18 and 4 cases respectively at 3, 6 and 9 hours and the CT attenuation values of common bile ducts were not changed untill 9 hours but slightly increased at 12 hours. Contrast media was noted in 7, 5, 6 and 5 cases at 3, 6, 9, and 12 hours in cystic duct and 8, 3, 2, 5 cases in duodenum. Contrast-filled cystic duct and duodenum were noted in 24 cases and 19 cases respectively on CT scans after fat meal. The CT attenuation values of gallbladder were increased in sequential periods of time and the difference of density of gallbladder between 3 hours and 6 hours was statistically significant(p=0.0001). The CT attenuation values of gallbladder at 6 hours were heighter than that in 3 hours, statistically. Opacified gallbladder were noted in 2 cases of fatty liver(n=2), 1 case of alcoholic liver disease(n=1), in 1 case of liver cirrhosis(n=1). Patients of gallbladder stone(n=2) or hepatocellular carcinoma (n=2) had non-opacified gallbladder on CT scans. CONCLUSION: The CT scans after oral contrast ingestion can show the morphological and functional aspects of gallbladder better than conventional oral cholecystography and can also show biliary trees and other surrounding structures, so it is helpful method for assessment of not only gallbladder diseases but also other hepatobiliary diseases.
Alcoholics ; Bile Ducts* ; Bile* ; Biliary Tract ; Carcinoma, Hepatocellular ; Cholecystography ; Common Bile Duct ; Contrast Media ; Cystic Duct ; Duodenum ; Eating* ; Gallbladder Diseases ; Gallbladder* ; Hepatic Duct, Common ; Humans ; Liver ; Meals ; Tomography, X-Ray Computed ; Volunteers

Cholangiocarcinoma is a form of adenocarcinoma arising from the intrahepatic or extrahepatic biliary epithelium. Apparent predisposing factors include some chronic hepatobiliary parasitic infsttations, congenital anomalies with ectatic ducts, sclerosing cholangitis and chronic ulcerative colitis and occupational exposure to possible biliary tract carcinogens. Patients with cholangiocarcinoma usually present with biliary obstruction, painless jaundice, pruritus, weight loss and acholic stools. Because the obstructing process is gradua1, the cholangiocarcinoma is often far advanced by the time it presents clinically. The diagnosis is most frequently made by cholangiography following ultrasound demonstration of dilated intrahepatic bile ducts. We report a case of common bile duct cancer spreading to gallbladder and common hepatic duct along the biliary mucosal epitherium and submucosal tissue in 68-year-old female patient along with a review of literature.
Adenocarcinoma ; Aged ; Bile Ducts, Intrahepatic ; Biliary Tract ; Carcinogens ; Causality ; Cholangiocarcinoma ; Cholangiography ; Cholangitis, Sclerosing ; Colitis, Ulcerative ; Common Bile Duct* ; Diagnosis ; Epithelium ; Female ; Gallbladder* ; Hepatic Duct, Common* ; Humans ; Jaundice ; Occupational Exposure ; Pruritus ; Ultrasonography ; Weight Loss

Carcinomas of the biliary tract are known to be more common in East Asia than in Western countries, but their exact histopathological characteristics and tumorigenesis are not well elucidated. To examine the histological and immunohistochemical characteristics of the biliary tract carcinomas according to their anatomical sites and to elucidate their tumorigenesis, we performed histological review and immunohistochemical study in a total of 135 cases of biliary tract carcinomas; 24 intrahepatic bile duct, 34 gallbladder, 51 common bile duct, and 26 periampullary carcinomas. Precancerous lesions were associated with 5 (20.8%) cases of intrahepatic duct carcinomas (dysplasia 5), 7 (20.6%) cases of gallbladder carcinomas (adenoma 5, dysplasia 2), 10 (19.6%) cases of common bile duct carcinomas (adenoma 7, dysplasia 3), and 2(7.7%)cases of periampullary carcinomas (adenoma 2). Immunohistochemically, c-erbB-2 expression in gallbladder carcinoma (21/34, 62%) was significantly higher than that of intrahepatic (8/24, 33%). Ki-67 indices were higher in common bile duct carcinomas (19%) than those of intrahepatic bile duct (14%) or periampullary carcinomas (12%). Overexpression of p53 gene product in the periampullary carcinomas (20/22, 77%) was higher than that of intrahepatic (12/24, 50%) or common bile duct carcinoma (26/51, 51%). In the precancerous lesions the c-erbB-2 expression was present in 29% of the gallbladder, 20% of the intrahepatic, 10% of the common bile duct precancerous lesions and none of the 2 cases of adenomas in the periampullary region. The p53 overexpression in the precancerous lesions was frequent, ranging from 43% to 60%. These results suggest that a mechanism involving p53 gene mutation and c-erbB-2 gene activation is present in the tumorigenesis in a significant number of the biliary tract carcinomas and they may be the early events in the tumorigenesis of the biliary tract carcinomas.
Adenoma ; Bile Ducts, Intrahepatic ; Biliary Tract* ; Carcinogenesis ; Common Bile Duct ; Far East ; Gallbladder ; Genes, erbB-2 ; Genes, p53