AJR 2003; 180:173-175
© American Roentgen Ray Society
Anomalous Pancreaticobiliary Junction Shown on Multidetector CT
Masanori Sugiyama1,
Hiroki Haradome2,
Taro Takahara2,
Nobutsugu Abe1,
Makoto Tokuhara1,
Tadahiko Masaki1,
Toshiyuki Mori1,
Junichi Hachiya2 and
Yutaka Atomi1
1 First Department of Surgery, Kyorin University School of Medicine, 6-20-2
Shinkawa, Mitaka, Tokyo 181-8611, Japan.
2 Department of Radiology, Kyorin University School of Medicine, Tokyo 181-8611,
Japan.
Received March 5, 2002;
accepted after revision June 3, 2002.
Address correspondence to M. Sugiyama.
Introduction
In the anomalous pancreaticobiliary junction, the pancreatic and bile ducts
unite outside the duodenal wall and form a long common channel (usually >
15 mm) [1]. The anomalous
junction is often associated with a choledochal cyst or a biliary tract
carcinoma [1,
2]. This anomaly can also cause
acute pancreatitis. Therefore, an anomalous junction should be diagnosed and
surgically treated before pancreaticobiliary complications or biliary tract
carcinomas develop. Endoscopic retrograde cholangiopancreatography (ERCP)
allows accurate diagnosis of the anomalous junction, but ERCP is invasive
[1]. Multidetector CT (MDCT) is
a recently developed technology that has provided extraordinary capacity for
fast data acquisition and thin collimation, which in turn allows a
high-quality multiplanar reformation and minimum-intensity-projection
algorithm and provides detailed information on the pancreaticobiliary ductal
anatomy
[3,4,5].
We report a case of an anomalous pancreaticobiliary junction associated with a
choledochal cyst, which was clearly shown on MDCT.
Case Report
A 21-year-old woman was admitted to our hospital for mild acute
pancreatitis, manifested by upper abdominal pain and hyperamylasemia (3580
U/L). She had no history of excessive alcohol intake or abdominal trauma.
Findings on sonography showed a normal-appearing pancreas and a dilated
extrahepatic bile duct without gallstones.
MDCT was performed using an Aquilion scanner (Toshiba Medical Systems,
Tokyo, Japan) with four high-resolution detectors. Unenhanced images of the
upper abdomen were initially obtained to define the craniocaudal extent of the
pancreaticobiliary region. A 100-mL dose of iohexol (Omnipaque 300; Nycomed
Amersham, Princeton, NJ) was then injected IV at a rate of 3 mL/sec. The
entire pancreaticobiliary region was imaged twice, at 45 sec (pancreatic
phase) and 70 sec (portal venous phase) after the start of the injection, by
using a collimation of 1 mm x 4 rows, a helical pitch of 6, a gantry
rotation speed of 0.5 sec per round, and a table speed of 12 mm/sec, during a
13-sec breath-hold. Coronal, paracoronal, and sagittal images of 1-mm
collimations were reconstructed at 1-mm intervals by multiplanar reformation.
Furthermore, minimum-intensity-projection images with slabs of 20 mm were
reconstructed.
MDCT clearly showed a dilated (15-mm) extrahepatic bile duct, a long
(16-mm) common channel, and nondilated normal pancreatic ducts (Figs.
1A,1B,1C).
The pancreaticobiliary junction was situated outside the duodenal wall in the
pancreas. These findings represented an anomalous pancreaticobiliary junction
associated with a choledochal cyst (Todani's type I)
[2]. MDCT with multiplanar
reformation showed diffuse thickening of the gallbladder wall but no
abnormalities of the bile duct wall or the pancreatic parenchyma.
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Fig. 1A. —21-year-old woman with anomalous pancreaticobiliary junction
associated with choledochal cyst. Portal venous phase 1-mm-section paracoronal
multiplanar reformation multidetector CT (MDCT) image shows dilated (15-mm)
extrahepatic bile duct (B). Arrowhead indicates duct of Santorini. G =
gallbladder.
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Fig. 1B. —21-year-old woman with anomalous pancreaticobiliary junction
associated with choledochal cyst. Portal venous phase 1-mm-section coronal
multiplanar reformation MDCT image shows long (16-mm) common channel (C) and
dilated extrahepatic bile duct (B). Arrowhead indicates pancreaticobiliary
junction. P = pancreatic duct, G = gallbladder.
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Fig. 1C. —21-year-old woman with anomalous pancreaticobiliary junction
associated with choledochal cyst. Portal venous phase 20-mm-slab paracoronal
minimum-intensity-projection MDCT image shows long common channel (C) and
dilated extrahepatic bile duct (B). Arrow represents duct of Santorini, and
arrowhead indicates pancreaticobiliary junction. P = pancreatic duct, G =
gallbladder.
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Findings on ERCP showed a 20-mm-long common channel and a choledochal cyst,
which confirmed the MDCT findings (Fig.
1D). The extrahepatic bile duct and gallbladder were resected, and
hepaticojejunostomy was performed. Pathologic examination of the surgical
specimen revealed mucosal hyperplasia of the gallbladder but no biliary tract
carcinoma.
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Fig. 1D. —21-year-old woman with anomalous pancreaticobiliary junction
associated with choledochal cyst. Endoscopic retrograde cholangiopancreatogram
shows long (20-mm) common channel and dilated (15-mm) extrahepatic bile duct.
Arrowhead indicates pancreaticobiliary junction.
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Discussion
Multiplanar reformation or minimum-intensity-projection MDCT provided
high-quality projection images of the the biliary tree and pancreatic ducts in
this patient, and the images were similar in appearance to those obtained by
ERCP. MDCT clearly showed an anomalous pancreaticobiliary junction (a long
common channel) associated with a choledochal cyst.
Because MDCT with three-dimensional reconstruction has been reported to
show the pancreaticobiliary ducts clearly and safely, pancreaticobiliary
anatomy and pathology can be well visualized on MDCT
[3,4,5].
However, to our knowledge, a finding on MDCT of an anomalous junction has
never been documented.
Although ERCP reliably depicts an anomalous pancreaticobiliary junction,
accurate noninvasive diagnostic modalities for the anomalous junction are
desirable because ERCP requires operator skill and entails a significant risk
of complications [1]. MR
cholangiopancreatography allows an accurate and noninvasive diagnosis of an
anomalous pancreaticobiliary junction and a choledochal cyst
[6]. Although endoscopic
sonography is safe and accurate for diagnosing such disorders, it is
operator-dependent [7].
MDCT has an advantage over ERCP and MR cholangiopancreatography, although
these three modalities provide projectional images of the pancreaticobiliary
ducts. MDCT with multiplanar reformation, particularly after contrast
enhancement, allows simultaneous depiction of the wall of the biliary tract
and pancreatic parenchyma and of the pancreaticobiliary duct lumen. This
advantage may assist in the diagnosis of associated pancreaticobiliary
disorders, such as biliary tract carcinomas
[1,
2] and mucosal hyperplasia of
the gallbladder [8].
The findings in our patient suggest the potential value of MDCT in
diagnosing an anomalous pancreaticobiliary junction and a choledochal cyst,
but further investigation is required to evaluate the usefulness of MDCT for
diagnosing these disorders.
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Introduction
Case Report
