A carcinoid tumor of the bile duct represents between 0.2 and 2% of all gastrointestinal carcinoids, most of which are located in the gallbladder or in the ampulla of Vater. A carcinoid tumor of the extrahepatic bile duct is extremely rare. A 43-year-old man presented with epigastric discomfort for several months. An abdominal ultrasound revealed a mass of the common bile duct. An endoscopic retrograde cholangiopancreatographic (ERCP) examination showed a 1.5 cm sized filling defect in the distal common bile duct and marked dilatation of the common bile duct and intrahepatic bile ducts. A 7 F endoprosthesis was put in place during the examination. The histological finding following an intralesional biopsy was a carcinoid tumor. We performed a pylorus preserving pancreaticoduodenectomy. The final pathological diagnosis was a well-differentiated carcinoid tumor of a malignant nature.
Adult ; Ampulla of Vater ; Bile ; Bile Ducts ; Bile Ducts, Extrahepatic ; Bile Ducts, Intrahepatic ; Biopsy ; Carcinoid Tumor ; Common Bile Duct ; Dilatation ; Gallbladder ; Humans ; Hypogonadism ; Mitochondrial Diseases ; Ophthalmoplegia ; Pancreaticoduodenectomy ; Polyenes ; Pylorus

The frequency of anatomical variation of the bile duct system is relatively common. The constitution of a normal biliary confluence by union of the right and left hepatic ducts is reported in only 57% (Couinaud 1957) to 72% (Healy & Schroy 1953) of cases. While many of these variations have little or no clinical importance, some cases cause symptoms and signs, or may lead to incorrect diagnosis and inappropriate management of biliary disorder. We report a case of rare extrahepatic bile duct anomaly in a 60-year-old man. His chief complaint was intermittent right upper quadrant pain for six months.There was a low union of both extrahepatic ducts and the cystic duct. The left extrahepatic duct fused with the right extrahepatic duct anteriorly and the long cystic duct ran alongside and parallel with the right and left extrahepatic duct before joining them. Distal CBD cancer was also combined.
Bile Ducts ; Bile Ducts, Extrahepatic* ; Constitution and Bylaws ; Cystic Duct ; Diagnosis ; Hepatic Duct, Common ; Humans ; Middle Aged

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

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

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

PURPOSE: This study addressed the feasibility and effect of surgical treatment of metachronous periampullary carcinoma after resection of the primary extrahepatic bile duct cancer. The performance of this secondary curative surgery is not well-documented. METHODS: We reviewed, retrospectively, the medical records of 10 patients who underwent pancreaticoduodenectomy (PD) for secondary periampullary cancer following extrahepatic bileduct cancer resection from 1995 to 2011. RESULTS: The mean age of the 10 patients at the second operation was 61 years (range, 45-70 years). The primary cancers were 7 hilar cholangiocarcinomas, 2 middle common bile duct cancers, and one cystic duct cancer. The secondary cancers were 8 distal common bile duct cancers and 2 carcinomas of the ampulla of Vater. The second operations were 6 Whipple procedures and 4 pylorus-preserving pancreaticoduodenectomies. The mean interval between primary treatment and metachronous periampullary cancer was 20.6 months (range, 3.4-36.6 months). The distal resection margin after primary resection was positive for high grade dysplasia in one patient. Metachronous tumor was confirmed by periampullary pathology in all cases. Four of the 10 patients had delayed gastric emptying (n = 2) or pancreatic fistula (n = 2) after reoperation. There were no perioperative deaths. Median survival after PD was 44.6 months (range, 8.5-120.5 months). CONCLUSION: Based on the postoperative survival rate, PD may provide an acceptable protocol for resection in patients with metachronous periampullary cancer after resection of the extrahepatic bile duct cancer.
Ampulla of Vater ; Bile Ducts, Extrahepatic* ; Cholangiocarcinoma ; Common Bile Duct ; Cystic Duct ; Gastric Emptying ; Humans ; Medical Records ; Neoplasms, Second Primary ; Pancreatic Fistula ; Pancreaticoduodenectomy* ; Pathology ; Reoperation ; Retrospective Studies ; Survival Rate

Percutaneous transhepatic cholangiography(PTC) is of value in differential diagnosis of cholestatic diseases. Authors had performed PTC in 120 patients with flexible needle of 23 gauge at the Department of Radiology, KangNam St, Mary's Hospital and Myung Dong St. Mary's Hospital during the period from Jan. 1976 to April 1980. PTC was accomplished successfully in 112 of 120 patients. Diagnoses included cholangiocarcinomas (27 cases), arcinomas ofpancreas head (21 cases), ampullary carcinomas (4 cases), metastatic carcinomas(4 cases), metastatic carcinomas (5cases), bile duct stones(27 cases), sclerosing cholangitis(6 cases), hepatitis(6 cases), liver cirrhosis(6 cases), post operative adhesions(5 cases), chronic pancreatitis(3 cases), stomach carcinomas(3 cases), clonorchiasis(2cases), blood clot (1 case), and remaining normal 4 cases. Some characteristic PTC findings were (1) segmentalannular narrowing and abrupt complete obstruction and polypoid filling defects of the bile duct incholangiocarcinoma, (2) typical nipple or rat-tail appearance of the distal commmon bile duct in pancreatic headcarcinoma, (3) single or multiple sharply and smoothly outlined filling defects whthin bile duct in all cases ofstones, (4) complete obstruction with shallow concavity in ampullary carcinoma, (5) diffuse or segmental narrowingof the intrahepatic bile duct and common bile duct in sclerosing cholangitis, (6) multiple tiny polypoid fillingdefects of gallbladder, common hepatic duct, and common bile duct in clonorchiasis, (7) normal appearance inhepatitis. The overall diagnostic accuracy of PTC in 66 operated cases was 89.4%, and complications following the examination were signficantly reduced by using a fine flexible needle(23 gauge). From the present study it is concluded as follows; 1. To evaluate obstructed or stenosed site accurately, aspiration of bile juice must bepreceded by a 23 gauge needle connected to either 10mo or 5ml syringe. 2. To diagose carcinoma of hte ampullaryportion, serial spot filmings were indispensible ot demonstrated modified appearance of obstructive lesions due tocontraction of Oddi sphincter. 3. In contrast to other reports, the most common site of cholangiocarcinomas wasthe common hepatic duct (12 of 27 cases) in our series. Rat-tail appearance was seen in both pancreatic headcarcinoma and carcinoma involving the distal end of the common bile duct. 4. PTC was a more valuable method for diagnosis of clonorchiasis.
Bile ; Bile Ducts ; Bile Ducts, Intrahepatic ; Cholangiocarcinoma ; Cholangiography ; Cholangitis, Sclerosing ; Clonorchiasis ; Common Bile Duct ; Diagnosis ; Diagnosis, Differential ; Gallbladder ; Head ; Hepatic Duct, Common ; Humans ; Liver ; Methods ; Needles ; Nipples ; Sphincter of Oddi ; Stomach ; Syringes

A 66-year-old male was admitted to the department of surgery, at the Presbyterian Medical Center due to right upper quadrant pain. Tumor marker studies reported CEA and CA19-9 elevation. Liver function test was normal. Ultrasonography and computed tomography showed a single infiltrative tumor in the left lobe of liver, multiple lymphadenopathies around the common hepatic duct and intrahepatic bile duct dilatation of the left lobe. The gallbladder was nonspecific. During laparotomy, we found an ill-marginated and infiltrative tumor in the left lobe of liver, multiple enlarged lymph nodes around the common hepatic duct and cystic duct, and mild thickening of the gallbladder fundus wall. Left hepatic lobectomy and cholecystectomy were performed. Pathologic findings revealed that the liver tumor was a moderated differentiated adenocarcinoma with extension to the pericystic and pericommon hepatic lymph nodes and focal adenocarcinoma in situ of gallbladder mucosal wall with clear cystic duct resection margin. We therefore report a rare case of synchronous double primary cancer of the intrahepatic bile duct and gallbladder.
Adenocarcinoma ; Aged ; Bile Ducts, Intrahepatic* ; Cholecystectomy ; Cystic Duct ; Dilatation ; Gallbladder* ; Hepatic Duct, Common ; Humans ; Laparotomy ; Liver ; Liver Function Tests ; Lymph Nodes ; Male ; Protestantism ; Ultrasonography

In a jaundiced patient, it is important to ascertain as early as possible whether the bile duct is dilated. Ultrasonography, computed tomography & conventional cholangiography are widely accepted methods of determining the size of the extrahepatic bile ducts. But there is a considerable discrepancy among the size of the bile duct as measured from them. So the author analyzed and compared the respective diameters of the bile ducts in Korean normal adults as measured from cadaver, IV cholangiography, ultrasoud and computed tomography. The materials were 45 cases of cadaver, 38 cases of IV cholangiography, 100 cases of ultrasonography & 55 cases of computed tomography. The results were as follows ; 1. The diameters of the bile ducts were 7.58±2.26mm at CHD & 8.04±2.42mm at CBD from cadaver ; 5.38±1.90mm at CHD & 6.58±2.37mm at CBD from IV cholanglography ; 3.24±1.13mm at CHD & 4.71±1.48mm at CBD from ultrasonography ; and 4.56±1.51mm at CHD & 5.87±1.68mm at CBD from computed tomography. 2. The diameter of the bile duct was greatest in cadaver, and then reduced in IV cholangiography, computed tomography and ultrasonography in this orde.r 3. There were no size discrepancy between the diameter of the common hepatic duct and that of the common bile duct. 4. There were no discrepanry of the diameter of the bile duct by sex.
Adult* ; Bile Ducts* ; Bile Ducts, Extrahepatic ; Bile* ; Cadaver ; Cholangiography ; Common Bile Duct ; Hepatic Duct, Common ; Humans ; Ultrasonography

BACKGROUND: Knowledge of bile duct anatomy is largely obtained through cholangiography. However, it is sometimes difficult to follow the intrahepatic segmental bile ducts and to define the extent of pathology precisely. Basically, the images on cholangiography are projected ones, so they do not provide the spatial concept. In contrast, sequential slices of CT contain information on the threedimensional structure. Purpose : We aimed to assess the intrahepatic bile duct anatomy by examining the CT. METHODS: The spiral CT images of 42 patients with bile duct dilatation were examined serially from above downward. Intrahepatic bile ducts were followed up to the third-order branches, classified according to the level of branching and compared with those on cholangiography. Further, the relationship between the segmental bile ducts and portal veins were evaluated. RESULTS: At or below the level of convergence of the ventral(V) and dorsal(D) branches of VIII segment, the posterior bile duct(Bp) arises from right or common hepatic duct(VDP, or VD-P). Below this level, the Bp descends more than 8mm and branches into VI segmental branch(B6) and the posterior trunk(Pr), or it branches directly into B6 and Pr without definite descending portion(Pd). VDP-Pd- Pr,B6(high level of branching of Bp with Pd) was observed in 22, VDP-Pr,B6(high level of branching of Bp without Pd) in 3, VD-P-Pd-Pr,B6(low level of branching of Bp with Pd) in 12, and VD-P-Pr,B6(low level of branching of Bp without Pd) in 4. These findings were closely correlated with those on cholangiography. Regarding the relationship of the segmental bile ducts and portal veins(PV), all right anterior bile ducts were located superior-medial to the PV, and the trunk of right posterior bile duct(Pr) ran superior-lateral to PV in 38 and superior-medial in 4 patients. Most segmental branches of VI and VII segments ran anterior-lateral-superior to PV(VI:39/40, VII:17/18). The Bp coursed above(and behind) the right anterior portal vein(APV) in 39, and below(and in front of) the APV in 3, of which 2 cases had separate and low origin of Bp from common hepatic duct. CONCLUSION: CT was useful to understand intrahepatic bile duct anatomy.
Bile ; Bile Ducts ; Bile Ducts, Intrahepatic* ; Cholangiography ; Dilatation ; Hepatic Duct, Common ; Humans ; Pathology ; Portal Vein ; Tomography, Spiral Computed