DOI:10.2214/AJR.05.1570
AJR 2007; 189:W344-W347
© American Roentgen Ray Society
MR Cholangiography of Accessory Bile Duct Connected to the Stomach
Jei Hee Lee1,2,
Jeong-Sik Yu1,
Mi-Suk Park3,
Dong Sup Yoon4 and
Seok Woo Yang5
1 Department of Radiology, Yonsei University College of Medicine, YongDong
Severance Hospital, 146-92 Dogok-Dong, Gangnam-Gu, Seoul, Republic of Korea,
135-720.
2 Department of Radiology, Ajou University School of Medicine, Suwon, Republic
of Korea.
3 Department of Radiology, Yonsei University College of Medicine, Severance
Hospital, Seoul, Republic of Korea.
4 Department of Surgery, Yonsei University College of Medicine, YongDong
Severance Hospital, Seoul, Republic of Korea.
5 Department of Pathology, Yonsei University College of Medicine, YongDong
Severance Hospital, Seoul, Republic of Korea.
Received September 4, 2005;
accepted after revision November 8, 2005.
WEB This is a Web exclusive article.
Address correspondence to J. S. Yu
(yjsrad97{at}yumc.yonsei.ac.kr).
Keywords: abdominal imaging • biliary system • MR • cholangiopancreatography
Introduction
Accessory bile ducts, often draining a segment of the right lobe of
the liver into the common bile duct or the gallbladder, have been found at as
many as 4% of necropsies [1].
Accessory bile ducts connected to the gastrointestinal tract are extremely
rare [1,
2]. Since the first report of
double bile duct draining into the gastrointestinal tract as a congenital
anomaly registered by Vesalius in 1543, more than 50 cases of double biliary
drainage have been reported worldwide
[2].
We describe a case of accessory bile duct that connected the caudate lobe
of the liver to the stomach in which MR cholangiography (MRC) showed the
biliary anomaly and provided sufficient evidence for development of an
appropriate surgical plan. Subsequent intraoperative cholangiography
supplemented the imaging diagnosis, and surgical resection was performed. To
our knowledge, there have been no reported cases of MRC diagnosis of accessory
bile duct connected to the gastrointestinal tract.
Case Report
A 69-year-old man was admitted to our hospital with a 4-day history of
epigastric pain and fever (40.4°C). Physical examination revealed slight
tenderness of the right upper quadrant of the abdomen. Laboratory tests showed
leukocytosis (WBC count, 23,750/mm3) and an elevated alkaline
phosphatase level (366 IU/L). Results of liver function tests were normal.
Contrast-enhanced CT showed a cystic lesion with tubular configuration
connected to the caudate lobe of the liver and extending to the lesser
curvature of the gastric antrum through the anterior aspect of the neck of the
pancreas (Fig. 1A).
Inhomogeneous contrast enhancement of the liver parenchyma was associated with
minimal intrahepatic bile duct dilatation and periportal tracking due to
cholangitis. A loculated fluid collection around the caudate lobe of the liver
also was found (Fig. 1A).
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Fig. 1A —69-year-old man with accessory bile duct connected to
stomach. Abdominal CT scan shows cystic lesion (white arrowhead) with
tubular configuration connected to caudate lobe of liver with inhomogeneous
contrast enhancement of liver parenchyma associated with minimal intrahepatic
bile duct dilatation due to cholangitis. Loculated fluid collection (black
arrowhead) around caudate lobe of liver is evident.
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To determine whether a biliary problem had caused cholangitis, MRC was
performed with a 1.5-T superconducting unit (Magnetom Vision, Siemens Medical
Solutions). A singleshot RARE sequence (TR/effective TE, infinity/1,200;
echo-train length, 240; flip angle, 150°) and multislice half-Fourier RARE
sequence (TR/effective TE, infinity/95; echo-train length, 128; flip angle,
150°) were used. The slab of a single-shot RARE sequence was obtained at
various angles to obtain optimal visualization of the bile ducts. The
multislice half-Fourier RARE images were obtained at an angle 20-35° to
the coronal plane to simulate a right anterior oblique projection on direct
cholangiography. Each of the imaging sets was obtained during a breath-hold. A
phased-array torso coil was used for body imaging.
MRC revealed a curved tubular area of hyperintensity along the lesser
curvature side of the gastric antrum running parallel to the common bile duct
(Fig. 1B). MRC showed no
characteristic signs of cholangitis in the intrahepatic portion of the bile
duct (Fig. 1B). Sonographically
guided percutaneous diagnostic needle aspiration of the lesion was performed,
and the cystic lesion collapsed (Fig.
1C). After treatment with antibiotics, the symptoms resolved, and
the WBC count returned to normal.
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Fig. 1B —69-year-old man with accessory bile duct connected to
stomach. MR cholangiogram shows entire course of tubular lesion (white
arrowheads), which runs parallel to common bile duct (black
arrowhead). Proximal portion is connected to intrahepatic bile duct, and
distal portion ends at lesser curvature of gastric antrum. Fluid-filled
stomach (white arrows) is evident. Junction of common bile duct
(black arrowhead) and main pancreatic duct (black arrow) is
present in common channel behind stomach.
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Follow-up abdominal CT 25 days after the initial CT examination showed that
the fluid collection, located in the lesser sac around the caudate lobe of the
liver and extending to the focally thickened posterior wall of the gastric
antrum, was still evident (Fig.
1D). Gastroscopy revealed localized fibrotic scarring in the
posterior wall of the antrum without a definite mucosal lesion. Because a
congenital anomaly of the biliary tract potentiating recurrent inflammation
was suspected, surgical intervention was performed. In the operative field, a
tubular structure connecting the antrum of the stomach to the caudate lobe of
the liver and partially passing through the pancreatic parenchyma was
identified. After direct cannulation of the tubular structure, a diagnostic
tubogram was obtained, and the intrahepatic bile ducts, common hepatic duct,
and cystic duct all appeared opaque after filling of the anomalous tubular
structure (Fig. 1E).
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Fig. 1D —69-year-old man with accessory bile duct connected to
stomach. Follow-up abdominal CT scan shows that tubular lesion (not shown)
terminated at lesser curvature of thickened gastric antrum
(arrow).
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Fig. 1E —69-year-old man with accessory bile duct connected to
stomach. Operative cholangiogram obtained by means of cannulation of accessory
bile duct (black arrowheads) shows opaque intrahepatic bile duct,
common hepatic duct (white arrowhead), cystic duct (arrow),
and common bile duct. Accessory bile duct is linked to intrahepatic bile duct,
and intrahepatic channel communicates with common bile duct. There is no
direct communication via orifice between accessory bile duct and stomach.
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There was no evidence of cholangitis in the intrahepatic bile duct. The
lowermost portion of this anomalous tubular structure was blunted distally,
and there was no evidence of contrast material entering the stomach. Combined
with partial dissection of the body of the pancreas and wedge resection of the
posterior wall of the gastric antrum, the anomalous tubular structure was
excised from the caudate lobe of the liver. The internal epithelium of the
tubular lesion reacted to cytokeratin 7 but not to cytokeratin 20. The
pathologic diagnosis was accessory bile duct. The distal portion of the
accessory bile duct appeared contiguous with the gastric antrum, and there was
fibrotic scarring without an identifiable opening to the gastric mucosa (Figs.
1F and 1G).
Discussion
Double extrahepatic bile ducts with separate openings into the
gastrointestinal tract or ectopic drainage of the common bile duct (except
into the major duodenal papilla) are extremely rare
[2]. Because of its rarity,
various terms have been used to describe an anomalous extra communication
between the bile duct and the gastrointestinal tract. This pathologic
condition has been called accessory bile duct, accessory common bile duct, and
double common bile duct
[1-5].
Accessory common bile duct has been described
[5] as a channel of an aberrant
common bile duct that does not open into the major duodenal papilla and
therefore is a source of communication with the gastrointestinal tract between
the upper portion of the lesser curvature of the stomach and either the
pancreatic duct or the duodenum above the major papilla. The modified
classification system currently used is based on Goor and Ebert's
[6] morphologic grouping and
consists of the four following configuration subtypes
[5]: 1, common bile duct with a
septum within the lumen; 2, common bile duct that bifurcates and produces
independent drainage tracks; 3, double biliary drainage without communicating
channels (3a, without intrahepatic communicating channels; 3b, with
intrahepatic communicating channels); 4, double biliary drainage with one or
more communicating channels. Because MRC showed double biliary drainage
without an extrahepatic communicating channel, our case can be categorized as
type 3b. Furthermore, operative cholangiography performed by cannulation of
the accessory bile duct showed an opaque accessory bile duct, intrahepatic
bile duct, common hepatic duct, and common bile duct. It is evident that an
accessory bile duct was linked directly to the intrahepatic bile duct and that
there was an intrahepatic communicating channel between the common bile duct
and the accessory bile duct.
Kanematsu et al. [2]
reported that accessory bile ducts draining into the gastrointestinal tract
and opening into the duodenum, stomach, and pancreatic duct occurred with
incidences of 52%, 46%, and 2%, respectively. The orifice of the accessory
bile duct draining into the stomach was located in the lesser curvature of the
gastric antrum, angle, lower body, midbody, and upper body.
An accessory bile duct can cause complications such as calculous
formations, cholangitis, and cholecystitis. On rare occasions, it can cause
liver abscess, pancreatitis, pancreatic cancer, gallbladder cancer, gastric
cancer, and ampullary cancer
[1,
2,
5]. Patients without symptoms
should be carefully observed for the onset of serious biliary tract and
gastrointestinal disease [2].
Patients with severe symptoms may need surgical treatment, as in the case of
our patient, in whom recurrent cholangitis developed.
According to one report [7],
specimens obtained from an accessory bile duct had mucosa and structure
similar to those of normal bile ducts, but sphincter muscles were not found at
the entrance to the gastrointestinal tract. In our case, the epithelium of the
accessory bile duct reacted to cytokeratin 7 (implying bile duct origin) but
did not react to cytokeratin 20 (which would have implied a gastrointestinal
tract origin). Because of the imaging features of the anomalous connection
between the bile duct of the caudate lobe and the stomach and because of the
positive reaction to cytokeratin 7, we concluded that our patient had an
accessory bile duct. In this case, gastroscopy revealed mucosal scarring at
the antrum with no ectopic opening. We propose that the orifice of the
accessory bile duct had at one time opened into the stomach. Repetitive
inflammation caused by reflux of the gastric contents probably induced
occlusion of the orifice of the accessory bile duct. Recurrent cholangitis
developed that may have been caused by bile stasis. A case of gastric cancer
due to longstanding mucosal irritation by bile juice at the site of the
biliary orifice in a patient with gastric opening of an accessory bile duct
has been reported [2].
MRC is a fast, noninvasive alternative to endoscopic retrograde
cholangiography for evaluation of the biliary tract. Technical improvement in
imaging sequences and the use of phase-array coils enable physicians to obtain
high-quality images comparable with those produced by ERCP. MR
cholangiopancreatography has been used not only to evaluate
choledocholithiasis and malignant obstruction but also to assess postsurgical
complications with or without anatomic variants of the biliary tract
[8,
9]. In this case of accessory
bile duct connected to the stomach, MRC showed the biliary anomaly and
provided the evidence for development of an appropriate surgical plan.
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Introduction
Case Report
