Sex: male
Age: 89 years
History
The patient has a history of ulcer disease, but no stomach resection had been performed. Cholecystectomy was performed one year before the current illness.
Laboratory data
Not available.
Physical findings
Normal.
Case text
The current history begins with bouts of septicemia and an outside US showed intrahepatic biliary dilatation. An attempt at an ERCP failed because of pyloric outlet obstruction.
Image 1-2
PTC.
Iodinated contrast 300 mgI/ml was used as contrast agent.
Image 3-7
CT of upper abdomen.
Axial scans of the upper abdomen. Intravenous and oral
contrast-enhancement.
Image 8-11
PTC.
Image 1-2
1. What are the findings?
A second puncture has been performed into the dorsocaudal segment branch ot the biliary tract of the right liver lobe. A catheter has been advanced into the common hepatic duct. There is an obstruction in the bile duct at the level of the junction between the common hepatic and cystic ducts.
Image 3-7
2. What are the findings on Image 3?
Intrahepatic biliary tract dilatation. The relation between the intrahepatic portal venous branches and the biliary tract is well seen. An incidental remark is made of a cyst in the left kidney.
3. What are the findings on Image 4?
The dilatation of the common hepatic and cystic ducts at the level of the junction between the two is well seen. Also the peripheral intrahepatic biliary duct dilatation is seen. The dilatation of the biliary system can be followed down to the cranial aspect of the head of the pancreas. There is seen a collateral vessel passing ventrally from the splenic vein.
4. What are the findings on Image 5?
The pancreatic duct is dilated in the body and tail of the pancreas. Several collateral vessels are seen in the ventral portion of the abdomen. A thickened pyloric area is present.
5. What are the findings on Image 6?
The infiltration extending from the head of the pancreas to the pyloric area, also extending dorsally towards the portal venous confluence, which is reduced in diameter, is well seen.
6. What are the findings on Image 7? What is your diagnosis?
The caudal portion of the head of the pancreas has a more normal appearance, and the common bile duct, which has a normal diameter, is seen at the level of the papilla of Vater. Collateral vessels are again seen ventral to the pancreatic bed. There is an infiltration surrounding the origin of the superior mesenteric artery.
The tentative diagnosis is unresectable pancreatic carcinoma.
Image 8-11
7. What are the findings on Image 8?
The catheter has been advanced to the duodenum. There is an obstruction of the proximal portion of the common bile duct, about 3 cm long. The distal common bile duct has a more normal appearance.
8. What are the findings on Image 9?
Wallstent has been placed through the obstruction with its distal end in the duodenum. There is a narrowing of the stent at the level of the obstruction, the proximal and distal portions of the stent has a more normal diameter.
9. What are the findings on Image 10?
After balloon dilatation of the obstructed segment, the diameter of the Wallstent at the level of the obstruction and distally are about the same.
10. What are the findings on Image 11?
Contrast injection shows a free flow of contrast from the intrahepatic biliary system to the duodenum.
The external drainage can be removed.
Final diagnosis
Pancreatic 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.