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Using MR Cholangiopancreatography to Reveal Anomalous Pancreaticobiliary Ductal Union in Infants and Children with Choledochal Cysts

¹ Department of Diagnostic Radiology, Yonsei University College of Medicine, 134 Shinchon-dong, Seodaemun-ku, Seoul, 120-752 Korea.
² Department of Pediatric Surgery, Yonsei University College of Medicine, Seodaemun-ku, Seoul, 120-752 Korea.
³ Department of Pediatrics, Yonsei University College of Medicine, Seodaemun-ku, Seoul, 120-752 Korea.

View larger version (12K): [in a new window]   Fig. 1A. —Classifications of types of choledochal cysts. (Adapted with permission [16]) Drawings depict types Ia, Ib, Ic, II, and III (A) and types IVa, IVb, and V (B) choledochal cysts.

View larger version (13K): [in a new window]   Fig. 1B. —Classifications of types of choledochal cysts. (Adapted with permission [16]) Drawings depict types Ia, Ib, Ic, II, and III (A) and types IVa, IVb, and V (B) choledochal cysts.

View larger version (11K): [in a new window]   Fig. 2. —Drawings show classifications of types of anomalous pancreaticobiliary ductal union. In type A anomalous pancreaticobiliary ductal union, narrowed common bile duct joins pancreatic duct at right angle. In type B union, pancreatic duct joins common bile duct at acute angle. Type C union is complicated by patent accessory pancreatic duct and fine, intricate network of ducts.

View larger version (127K): [in a new window]   Fig. 3A. —9-year-old girl with abdominal pain and recurrent pancreatitis. Coronal MR cholangiopancreatographic image (TR/effective TE, infinite/1055) obtained using single-shot fast spin-echo sequence shows type la choledochal cyst with type A anomalous pancreaticobiliary ductal union. Common channel (curved arrow) is dilated, and angle between distal common bile duct (short straight arrow) and pancreatic duct (long straight arrow) is obtuse.

View larger version (117K): [in a new window]   Fig. 4A. —3-year-old girl with abdominal pain and pancreatitis. Coronal MR cholangiopancreatographic image (TR/effective TE, infinite/1339) obtained using single-shot fast spin-echo sequence shows type IVa choledochal cyst with type B anomalous pancreaticobiliary ductal union. Dilated pancreatic duct and common channel containing stones (short arrow) are also evident. Dilated aberrant right posterior hepatic duct (long thin arrow) draining cystic duct (long thick arrow) inserts into common bile duct.

View larger version (97K): [in a new window]   Fig. 3B. —9-year-old girl with abdominal pain and recurrent pancreatitis. Intraoperative cholangiogram shows cystic dilatation of common bile duct and ectatic common channel. Overdistended choledochal cyst obscures union between common bile duct and pancreatic duct.

View larger version (137K): [in a new window]   Fig. 4B. —3-year-old girl with abdominal pain and pancreatitis. Intraoperative cholangiogram reveals findings that correlate well with MR cholangiographic findings. Arrow indicates aberrant right posterior hepatic duct.

View larger version (108K): [in a new window]   Fig. 5A. —5-year-old girl with abdominal pain, jaundice, and fever. Coronal MR cholangiopancreatographic image (TR/effective TE, infinite/1055) obtained using single-shot fast spin-echo sequence shows mild fusiform dilatation of common bile and hepatic ducts and of right and left intrahepatic ducts. Dilated main and accessory (arrow) pancreatic ducts are visible, whereas common channel cannot be seen.

View larger version (125K): [in a new window]   Fig. 5B. —5-year-old girl with abdominal pain, jaundice, and fever. Intraoperative cholangiogram shows stones (long arrow) impacted in common channel as well as dilated main and accessory (short arrow) pancreatic ducts.

View larger version (132K): [in a new window]   Fig. 5C. —5-year-old girl with abdominal pain, jaundice, and fever. Intraoperative cholangiogram obtained after resection of choledochal cyst shows type C anomalous pancreaticobiliary ductal union. In addition to dilated common channel (short arrow), ectatic communicating channel (long arrow) is apparent between main and accessory pancreatic ducts.

View larger version (96K): [in a new window]   Fig. 6A. —6-year-old girl with jaundice. Coronal MR cholangiopancreatographic image (TR/effective TE, infinite/1004) obtained using single-shot fast spin-echo sequence shows type IVb choledochal cyst that is causing dilatation of proximal common bile duct and short segmental dilatation of distal common bile duct (arrow). Type of anomalous pancreaticobiliary ductal union cannot be determined.

View larger version (109K): [in a new window]   Fig. 6B. —6-year-old girl with jaundice. Intraoperative cholangiogram shows type of choledochal cyst that is concordant with that shown on MR cholangiopancreatography. Arrow indicates stenotic segment between cysts. Type of anomalous pancreaticobiliary ductal union cannot be determined in this image.

View larger version (117K): [in a new window]   Fig. 6C. —6-year-old girl with jaundice. Intraoperative cholangiogram obtained after resection of proximal part of choledochal cyst reveals that type of anomalous pancreaticobiliary ductal union is type B.

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