The presence of a common channel and associated pancreaticobiliary diseases: a prospective ERCP study

The role of 64-slice CT following perfusion with iohexol via the hepatopancreatic ampulla in assessing pancreaticobiliary junctions

The aim of this study was to delineate the structure of the pancreatic and biliary ducts in premature infants using a novel imaging method. The duodenal papillae of 30 premature infant cadavers were dissected. The pancreatic and biliary ducts were visualized using 64-detector multislice spiral computed tomography (MSCT). Contrast agent was injected into the duodenal papilla via the hepatopancreatic ampulla of Vater. MSCT scanning revealed both the pancreatic and biliary ducts as well as the common channel in 18 cases. The bile duct was visualized in the remaining 12 cases. Four patterns of the pancreaticobiliary ductal junction were noted: Y-type (73.3%), U-type (13.3%), V-type (6.7%), and II-type (6.7%). The results showed that MSCT and three-dimensional reconstruction can be used to visualize the junction pattern and common channel of the pancreatic and biliary ducts, and the structure of the surrounding tissue, in premature infants.

Higher expression of phosphorylated myosin regulatory light chain in the common bile duct in pancreaticobiliary maljunction accompanied by bile duct dilatation in children: a post-mortem observational study

PURPOSE

To examine the content of phosphorylated myosin regulatory light chain (P-MLC20) and myosin light-chain kinase (MLCK) in the common bile duct of pediatric patients with pancreaticobiliary maljunction (PBM) accompanied by bile duct dilatation (BDD), and investigate their potential role in PBM accompanied by BDD.

METHODS

Twenty-one specimens of the common bile duct from pediatric patients with PBM accompanied by BDD were collected. P-MLC20 was examined with immunohistochemistry. The expression of P-MLC20 and MLCK was also examined with Western blot. Twenty-one specimens of the common bile duct from pediatric patients without PBM and BDD were used as controls.

RESULTS

The mean optical density (MOD), mean labeling intensity (MLI) and minimum qualifying scores (MQS) of P-MLC20 were 115.6856 ± 58.1634, 21.7125 % ± 9.6555 and 21.3531 ± 6.5255, respectively. In the control group, MOD, MLI and MQS were 96.5581 ± 9.7859, 11.1813 % ± 3.6208 and 10.7819 ± 3.5323, respectively. There was no significant difference in MOD between the two groups (P > 0.05), whereas there was a significant difference in MLI and MQS between the two groups (P < 0.05). The expression of P-MLC20 and MLCK, as determined with Western blot, was also significantly higher in the PBM group than in the control group (P < 0.05).

CONCLUSION

P-MLC20 is associated with increased contractile force of the smooth muscle of the common bile duct in pediatric patients with PBM accompanied by BDD. The enhanced expression of P-MLC20 in the common bile duct probably contributes to increased bile duct pressure in PBM via the MLCK pathway.

Multidetector computed tomography (MDCT) manifestations of the normal duodenal papilla

OBJECTIVE

This study aimed to investigate Multidetector Computed Tomography (MDCT) manifestations of the normal duodenal papilla, thereby improving the knowledge on the CT manifestations of the normal anatomy of the duodenal papilla.

METHODS

A retrospective study was conducted by reviewing the CT results of 70 normal duodenal papilla cases examined by 64-MDCT. The analysis particularly focused on the position, size, morphology, and enhancement pattern of the duodenal papilla, as well as the ampulla of Vater.

RESULTS

In axial images, the average base diameter of the duodenal papilla was (7.3 ± 1.4)mm, whereas the average height was (6.5 ± 1.8)mm. Majority of the duodenal papilla (52.9%, 37/70) showed a round shape. In most cases (97.1%, 68/70), the duodenal papilla were located at the middle and lower third of the descending duodenum. In 84.3% of the cases (59/70), the arterial phase enhanced CT scan images were optimal for the visualization of the papilla. The "target sign" could be clearly identified from arterial phase images in 71.4% (50/70) of the cases. In 72.9% (51/70) of the cases, the ampulla of Vater had a common channel (Y type).

CONCLUSION

64-MDCT can clearly visualize the normal anatomy of the duodenal papilla and surrounding structures, thereby providing valuable information for the diagnosis and treatment of diseases in this region.

Imaging findings in 75 pediatric patients with pancreaticobiliary maljunction: a retrospective case study

BACKGROUND

Pancreaticobiliary maljunction (PBM) is often associated with congenital choledochal cyst, protein plugs and pancreatitis. Early diagnosis and timely treatment largely depend on imaging. We assessed a series of PBM in children, comparing imaging procedure with histological and pathological findings with regard to diagnosis.

METHODS

A retrospective analysis was conducted in 75 pediatric patients with PBM. PBM was defined as common channel at >5 mm. Two radiologists assess the shape of the bile duct and gallbladder, pancreatitis, surgical pathology, symptom profiles, operative notes and pathological records were compared with the imaging findings.

RESULTS

Dilatation of the bile duct was detected in 45 subjects out of the 46 subjects who underwent computed tomography (CT) and nine was diagnosis as PBM. Forty out of 41 subjects were revealed bile duct dilatation in ultrasonography (US). Bile duct dilatation was seen in 59 out of 60 subjects receiving magnetic resonance cholangiopancreatography (MRCP) and 39 were diagnosed as PBM. Seventy-four out of 75 subjects successfully underwent intraoperative cholangiography (IOC); a diagnosis of PBM was established in 60 cases based on IOC alone. The diagnosis rate of pediatric PBM varied significantly among the four groups (P < 0.0001). Pair-wise comparison showed a significant difference between the groups of MRCP and CT (P < 0.0001), MRCP and US (P < 0.0001), IOC and CT (P < 0.0001), IOC and US (P < 0.0001), CT and US (P = 0.0027), and there is no significant difference between the groups of IOC and MRCP (P = 0.0502).

CONCLUSION

US, IOC, CT and MRCP are valuable in showing dilatation of the bile duct and complications in pediatric PBM. MRCP is non-invasive, gives clear views of the pancreaticobiliary junction and should be the first choice for the diagnosis of PBM in children.

Etiology and diagnosis of acute biliary pancreatitis

Establishing a biliary etiology in acute pancreatitis is clinically important because of the potential need for invasive treatment, such as endoscopic retrograde cholangiopancreatography. The etiology of acute biliary pancreatitis (ABP) is multifactorial and complex. Passage of small gallbladder stones or biliary sludge through the ampulla of Vater seems to be important in the pathogenesis of ABP. Other factors, such as anatomical variations associated with an increased biliopancreatic reflux, bile and pancreatic juice exclusion from the duodenum, and genetic factors might contribute to the development of ABP. A diagnosis of a biliary etiology in acute pancreatitis is supported by both laboratory and imaging investigations. An increased serum level of alanine aminotransferase (>1.0 microkat/l) is associated with a high probability of gallstone pancreatitis (positive predictive value 80-90%). Confirmation of choledocholithiasis is most accurately obtained using endoscopic ultrasonography or magnetic resonance cholangiopancreatography. This Review discusses the pathogenesis of ABP and the clinical techniques used to predict and establish a biliary origin in patients with suspected ABP.

Utility of narrow band imaging for identification of the orifice of the bile duct during ERCP

Exact identification of the orifice of the bile duct in the major duodenal papilla is required for selective cannulation during endoscopic retrograde cholangiopancreatography (ERCP). However, there are some cases in which the orifice is unclear. The narrow band imaging (NBI) system is an endoscopic imaging technique based on modification of spectral features that enhances visualization of the vascular network. On NBI, bile appears as a bright red fluid, and it is enhanced in the digestive tract. We report two cases in which the NBI was useful for identification of the orifice of the bile duct during ERCP. We recommend the NBI technique before cannulation in cases where the orifice is unclear on the standard image.

Congenital choledochal malformation: not just a problem for children

Choledochal cysts remain relatively uncommon in Western Europe and the US, although they are appreciably more common in Asia. Their aetiology remains obscure although abnormalities of the pancreaticobiliary junction may be the primary pathology in some, with biliary dilatation following reflux of activated pancreatic secretions. Most anomalies will present in childhood with obstructive jaundice or abdominal pain; a proportion may only present for the first time during adulthood, and some of these will show malignant transformation. The classical triad of pain, jaundice and a palpable mass is, however, not common. Complete cyst excision, where possible, and biliary reconstruction remain the aims for most types although there is still some controversy about the type of reconstruction. Laparoscopic reconstruction is possible but is still very much an advanced technique. The risk of long-term problems post-surgery is significant. Whether this is due to recurrent pancreatitis secondary to the retained common channel and/or a distal stump, or due to the development of biliary tract malignancy is still a cause for concern and indicates the need for adequate, prolonged follow-up.

Biliopancreatic reflux-pathophysiology and clinical implications

The common bile duct and the main pancreatic duct open into the duodenum, where they frequently form a common channel. The sphincter of Oddi is located at the distal end of the pancreatic and bile ducts; it regulates the outflow of bile and pancreatic juice. In patients with a pancreaticobiliary maljunction, the action of the sphincter does not functionally affect the junction. Therefore, in these patients, two-way regurgitation (pancreatobiliary and biliopancreatic reflux) occurs. This results in various pathological conditions of the biliary tract and the pancreas. Biliopancreatic reflux could be confirmed by: operative or postoperative T-tube cholangiography; CT combined with drip infusion cholangiography; histological detection of gallbladder cancer cells in the main pancreatic duct; and reflux of bile on the cut surface of the pancreas. Biliopancreatic reflux occurs frequently in patients with a long common channel. Although the true prevalence, degree, and pathophysiology of biliopancreatic reflux remain unclear, biliopancreatic reflux is related to the occurrence of acute pancreatitis. Obstruction of a long common channel easily causes bile flow into the pancreas. Even if no obstruction is present, biliopancreatic reflux can still result in acute pancreatitis in some cases.

Choledochal cyst and anomalous pancreaticobiliary ductal union in adults: radiological spectrum and complications

Choledochal cyst and anomalous pancreaticobiliary ductal union (APBDU) are considered to be embryologically related to each other, and their complications are clinically important. This article illustrates the key imaging features of choledochal cysts and APBDU and their various associated abnormalities and complications. Complications of common bile duct are more common in APBDU with choledochal cyst, and complications of gallbladder are more common in APBDU without choledochal cyst.