Sex: male
Age: 75 years
History
Previously healthy.
Laboratory data
Not available.
Physical findings
None relevant.
Case text
75 - year old male, who developed abdominal pain and jaundice. An outside ultrasonography ( US ) showed dilatation of the intrahepatic biliary tract and stones in the gallbladder. An attempt at an endoscopic retrograde cholangio-pancreatography (ERCP) failed due to a pyloric outlet obstruction.
Image 1-2
Percutaneous transhepatic cholangiography (PTC).
Image 3-7
Computed tomography (CT).
Computed tomography of upper abdomen with intravenous administration of iodinated contrast 300 mgI/ml.
Image 8-11
PTC continued with iodinated contrast 300 mgI/ml.
Image 1-2
1. What are the findings on Image 1?
Biliary tract dilatation. The first fine-needle pass enters into the left hepatic duct, making it unsuitable for drainage. The second needle passes into the dorsocaudal segment branch of the right liver lobe. A fine-needle guidewire has been introduced.
2. What are the findings on Image 2?
A catheter has been advanced to the common hepatic duct. A total obstruction is present in the common hepatic duct at a level corresponding to the junction of the common hepatic and cystic ducts. The first fine-needle is still in place in the left hepatic duct.
Image 3-7
3. What are the findings on Image 3?
Intrahepatic biliary tract dilatation. The position of the bile duct just ventral to the portal vein in the hilum of the liver is well seen.
4. What are the findings on Image 4?
The cystic duct is dilated, and the fundus of the gallbladder is poorly delineated towards the gallbladder fossa in the liver. An incidental remark of renal cysts can also be done.
5. What are the findings on Image 5?
There are calcified stones in the gallbladder. There is an irregular soft-tissue infiltration extending from the gallbladder towards the liver parenchyma, but also extending medially to the hepatoduodenal ligament. The body and tail of the pancreas has a normal appearance, and there is no evidence of dilatation of the pancreatic duct.
6. What are the findings on Image 6?
The infiltration extendes to the portal venous confluence and the cranial area of the pancreas and the structures here cannot be clearly delineated. This level corresponds well to the level of obstruction in the biliary system as seen on the PTC.
7. What are the findings on Image 7?
The head of the pancreas looks normal. The non-obstructed common bile duct can be seen in the dorsal aspect of the pancreatic head. There are some irregular soft-tissue changes in the intra-abdominal fat just caudal to the liver edge.
Image 8-11
8. What is your temptative diagnosis according to looking at the previous examinations?
Gallbladder carcinoma with infiltration into the hepatoduodenal ligament and also towards the pylorus and gallbladder fossa, surgically non-resectable.
9. What are the findings on Image 8?
Guidewire and catheter system has been passed to the duodenum. The obstruction in the biliary duct is well delineated and is about 1 cm in length. The common bile duct distal to the obstruction is normal in diameter. Some contrast also enters the pancreatic duct.
10. What are the findings on Image 9?
A Wallstent has been inserted, it is placed through the obstruction. There is a reduced diameter at the level of the obstruction.
11. What are the findings on Image 10?
Balloon dilatation is performed on the Wallstent.
12. What are the findings on Image 11?
After dilatation the lumen of the stent at the level of the obstruction is the same as the lumen of the common bile duct distal to the obstruction. There is an unobstructed passage of contrast from the intrahepatic biliary radicles to the duodenum. The external catheter can then be removed.
Final diagnosis
Gallbladder carcinoma.
Differential diagnosis
See discussion.
Discussion
The findings at the PTC in these two cases are quite similar. However, when evaluating the CT’s a clear difference in the pattern is seen. In the first case, there is evidence of gallstone disease, but also an infiltration in the liver parenchyma at the fundus of the gallbladder extending towards the hilum of the liver and the hepatoduodenal ligament are present. There is no evidence of obstruction of the pancreatic duct or evidence of an expanding lesion in the pancreatic tissue itself. On these findings alone a gallbladder carcinoma, extending to the hepatoduodenal ligamnet, not surgically resectable, can be suspected, although a severe inflammatory lesion could present itself in quite a similar way. However, in view of the clinical presentation, an inflammatory lesion was deemed unlikely.
In the second case, the findings at the PTC were about the same. However, the patient had previously had a cholecystectomy and here there are CT signs of a lesion within the pancreas itself, with dilatation of the pancreatic duct. The infiltration shown extending to the portal venous confluence, the origin of the superior mesenteric artery and the pylorus makes the lesion surgically unresectable.
By utilizing the information of the infiltration pattern as seen with CT, the presence or absence of gallstones and pancreatic duct dilatation, it was possible to reach a tentative diagnosis in both patients. By analyzing the infiltration pattern a correct evaluation of non-resectability was made in both cases. Thus it was possible to differentiate between the two forms of disease clinically presenting themselves quite similarly, which were causing similar biliary duct obstruction, and to also safely place a Wallstent at the diagnostic PTC.