0 évaluation0% ont trouvé ce document utile (0 vote)
21 vues12 pages
AJR:203, July 2014 17 Abnormalities of the distal common bile duct and ampulla: Diagnostic Approach and Differential diagnosis Using Multiplanar Reformations and 3d Imaging Siva P. Raman, eliot k. Fishman. Es will ultimately require either MRCP or ERCP for further definitive evaluation.
AJR:203, July 2014 17 Abnormalities of the distal common bile duct and ampulla: Diagnostic Approach and Differential diagnosis Using Multiplanar Reformations and 3d Imaging Siva P. Raman, eliot k. Fishman. Es will ultimately require either MRCP or ERCP for further definitive evaluation.
AJR:203, July 2014 17 Abnormalities of the distal common bile duct and ampulla: Diagnostic Approach and Differential diagnosis Using Multiplanar Reformations and 3d Imaging Siva P. Raman, eliot k. Fishman. Es will ultimately require either MRCP or ERCP for further definitive evaluation.
Common Bile Duct and Ampulla: Diagnostic Approach and Differential Diagnosis Using Multiplanar Reformations and 3D Imaging Siva P. Raman 1
Elliot K. Fishman Raman SP, Fishman EK 1 Both authors: Department of Radiology, Johns Hopkins University, 601 N Caroline St, JHOC 3251, Baltimore, MD 21287. Address correspondence to S. P. Raman (srsraman3@gmail.com). Gast roi ntest i nal I magi ng Revi ew This article is available for credit. AJR 2014; 203:1728 0361803X/14/203117 American Roentgen Ray Society Keywords: 3D imaging, ampulla, ampullary carcinoma, common bile duct, CT, pancreatic adenocarcinoma DOI:10.2214/AJR.13.11288 Received May 24, 2013; accepted after revision July 2, 2013. F O C U S
O N : es will ultimately require either MRCP or ERCP for further denitive evaluation, but an accurate interpretation of the initial CT examination may allow the radiologist to prospectively suggest the correct diagnosis. Evaluation of Biliary Dilatation In general, the CBD should measure 7 mm or less in healthy patients, although the nor- mal duct may be dilated in older patients and those who have undergone cholecystectomy. Thus, overemphasizing CBD measurements, especially when the ducts are only mildly di- lated, should be avoided, particularly in pa- tients without symptoms (i.e., biliary colic, right upper quadrant pain, jaundice) or bio- chemical markers suggestive of biliary ob- struction [2]. In patients with borderline en- largement of the ducts without CT evidence of a discrete obstructing mass or other sus- picious imaging features, the best course of action may be to simply recommend corre- lation with clinical and biochemical mark- ers of obstruction rather than recommending MRCP or ERCP in every patient. Normal bile ducts on CT should have an almost imperceptible wall ( 1 mm), with only minimal enhancement on either arteri- T he distal common bile duct (CBD) and ampulla can be an extremely challenging location for the radiologist to assess: It can be difcult not only to differentiate a normal distal CBD with mild dilatation from a distal CBD with true pathologic dilatation but also, even once an abnormality has been identied, to provide the appropriate differ- ential diagnosis. The accurate radiologic evaluation of this location is of great impor- tance because periampullary tumors are the third most common type of gastrointestinal neoplasm, after colonic and gastric tumors, and because the different lesions found in this location can have markedly different prognoses [1]. This article seeks to provide the reader with a framework for interpreting CT stud- ies of the distal CBD and ampulla, including providing a differential diagnosis for ampul- lary and distal CBD abnormalities and le- sions, a perspective on when a dilated CBD requires further evaluation with MRCP or ERCP, and a discussion of the use of multi- planar reformations (MPRs) and 3D imaging to better assess the morphology of the dis- tal CBD and ampulla. Of course, many cas- OBJECTIVE. The distal common bile duct (CBD) and ampulla are extremely difcult sites to evaluate on CT. This article seeks to provide the reader with a framework and algo- rithmic approach to the evaluation of abnormalities involving the distal CBD and ampulla, including an emphasis on the use of multiplanar reformations and 3D imaging, the morpho- logic features on CT that suggest the presence of malignancy, and a differential diagnosis for abnormalities in this location. CONCLUSION. In our experience, both the distal CBD and ampulla are common sites of missed diagnoses for radiologists. Avoiding mistakes in interpreting imaging ndings in this location requires a systematic approach especially in the setting of unexplained biliary ductal dilatation. Rather than simply suggesting that MRCP or ERCP be performed for the ultimate diagnosis, radiologists can perform a careful CT evaluation using multiplanar refor- mations and 3D imaging to determine the correct diagnosis prospectively. A timely and cor- rect diagnosis is imperative because lesions in the ampulla and CBD can be very aggressive despite their small size. Raman and Fishman CT of the Distal CBD and Ampulla Gastrointestinal Imaging Review D o w n l o a d e d
f r o m
w w w . a j r o n l i n e . o r g
b y
1 8 0 . 2 4 6 . 4 0 . 8 2
o n
0 7 / 2 4 / 1 4
f r o m
I P
a d d r e s s
1 8 0 . 2 4 6 . 4 0 . 8 2 .
C o p y r i g h t
A R R S .
F o r
p e r s o n a l
u s e
o n l y ;
a l l
r i g h t s
r e s e r v e d
18 AJR:203, July 2014 Raman and Fishman al or venous phase images. In the setting of dilated bile ducts, the ducts must be carefully evaluated for the presence of focal or diffuse hyperenhancement on arterial or venous phase images; delayed enhancement, if delayed im- ages are acquired; focal or diffuse bile duct wall thickening; and a discrete mass. The same precepts traditionally used to analyze the bile ducts on ERCP are just as important to apply to CT as well: The CBD should be carefully evaluated for discrete sites of transition between dilated proximal ducts and a decompressed or narrowed dis- tal duct. Once a site of transition is found, any evidence of irregularity, abrupt narrow- ing, or shouldering at the transition point should raise suspicion for malignancy. Al- though this evaluation can be performed using the source axial images, the use of coronal and sagittal MPR images and 3D re- constructions can be vital [3]. Technique In any patient with a suspected pancreato- biliary abnormality, a dual-phase study with both arterial and venous phase images should be acquired. The arterial phase images are used to identify hypervascular tumors (i.e., ampul- lary carcinoid, pancreatic neuroendocrine tu- mors, hypervascular gastrointestinal stromal tumors), subtle biliary tree mucosal hyperen- hancement and thickening, and tumor neovas- cularity and to evaluate the arterial anatomy before surgery. The venous phase images are used to evaluate the liver and pancreas for tra- ditionally hypovascular tumors and metasta- ses, locoregional lymphadenopathy, and in- volvement of the venous vasculature by tumor [4]. Although delayed images are not routinely acquired, they may be added to the protocol if cholangiocarcinoma is prospectively thought to be a diagnostic consideration. Positive oral contrast material absolutely must be avoided in patients presenting with jaundice or a suspected mass in the pancre- as, ampulla, or duodenum: Not only will the positive contrast agent obscure any intralu- minal mass in the duodenum or near the am- pulla, but also streak artifact from the con- trast agent will make evaluation of subtle duodenal wall thickening or hyperenhance- ment near the ampulla difcult to perceive and can interfere with 3D postprocessing al- gorithms. Instead, a neutral contrast agent such as water or a barium suspension (VoL- umen, Bracco Diagnostics) should be used, and some portion of this contrast medium should be given to the patient immediately before scanning to maximize gastric and du- odenal distention [4]. After the acquisition of source axial imag- es and reconstruction of standard MPRs, we have found three image postprocessing re- construction algorithms (including 3D post- processing) to be the most useful for image interpretation: volume rendering (VR), min- imum intensity projections, and curved pla- nar reformations. VR is a complex, compu- tationally intensive computer algorithm that assigns a specic color and transparency to each voxel in a dataset on the basis of its at- tenuation and relationship to other adjacent voxels before presenting these data in a 3D display. The VR technique allows the best soft-tissue denition of any of the 3D re- construction tools and is a vital component of biliary analysis. This technique is useful not only for increasing the conspicuity of ob- structing lesions, but also for increasing the conspicuity of subtle biliary hyperenhance- ment and thickening [4, 5]. Minimum-intensity-projection reconstruc- tions rely on the same principles as maxi- mum-intensity-projection (MIP) imaging. However, unlike MIP reconstructions, which project the highest-attenuation voxels in a da- taset, minimum-intensity-projection recon- structions project the lowest-attenuation vox- els, making them extraordinarily valuable for visualization of uid-lled structures, such as the biliary tree or pancreatic duct, particularly when these structures are dilated or obstruct- ed. At our institution, although MIP images are not a major component of biliary tree 3D analysis, minimum-intensity-projection re- constructions are performed in every case, and we have experienced great success in identify- ing small tumors that were more conspicuous when using this imaging technique [6, 7]. Finally, given that the entire extrahepatic bile duct does not normally course in the cor- onal, sagittal, or axial plane, visualizing the entire duct on any given MPR or the source axial images can be impossible, making it more difcult to perceive sites of subtle wall thickening or even a discrete mass. Curved planar reformations, which are interactively created by the user as he or she identies the course of the duct, allow the entire CBD to be displayed in a single 2D image and are part of our routine evaluation [6, 8]. Differential Diagnosis Malignant Causes Ampullary adenomaAdenomas of the small bowel are relatively uncommon com- pared with those of the large bowel, and within the small bowel, adenomas are more common in the ileum and jejunum than in the duodenum. Within the duodenum, 10% of all duodenal polyps are ultimately found to be adenomas, and the most common loca- tion is in proximity to the ampulla of Vater [9]. These lesions are most common in elder- ly patients, and other than familial adenoma- tosis coli, no other clear risk factors for the development of ampullary adenomas have been described in the literature [9]. Ampullary adenomas are benign lesions that retain malignant potential: Similar to the adenoma-carcinoma sequence in the co- lon, these lesions usually contain foci of low- grade dysplasia and have the potential to de- velop higher-grade dysplasia and invasive carcinoma, particularly as they grow larger. Up to 60% of ampullary adenomas are ul- timately found to harbor at least some foci of invasive carcinoma (especially in large lesions), so the preoperative distinction be- tween an adenoma and an ampullary carci- noma is not relevant for the radiologist [9]. There are no dedicated descriptions of the imaging appearance of ampullary adenomas in the literature to date; in our experience, although ampullary adenomas may have a slightly lesser predilection for causing severe ductal obstruction, their CT appearance is not signicantly different from that of am- pullary carcinomas (Figs. 1 and 2). CholangiocarcinomaAlthough cholangio- carcinomas of the extrahepatic duct have a strong predilection for the proximal one third of the duct, up to 20% of lesions oc- cur in the distal one third and 95% of pa- tients show ductal obstruction at the time of diagnosis [10]. Traditionally, both intra- hepatic and extrahepatic cholangiocarcino- mas have been classied into three different morphologic subtypes, each of which pres- ents with a different appearance on imaging: mass-forming cholangiocarcinoma, periduc- tal inltrating cholangiocarcinoma, and in- traductal cholangiocarcinoma. The mass-forming cholangiocarcinoma is the easiest of the three subtypes to diag- nose: It usually presents as a discrete mass or nodule that obstructs the extrahepatic bile duct. This mass does not have to be partic- ularly large to obstruct the duct, and both the source axial images and coronal MPRs should be scrutinized for evidence of a dis- crete nodule. Like intrahepatic cholangio- carcinoma, these lesions can show some hy- pervascularity on arterial phase images and D o w n l o a d e d
f r o m
w w w . a j r o n l i n e . o r g
b y
1 8 0 . 2 4 6 . 4 0 . 8 2
o n
0 7 / 2 4 / 1 4
f r o m
I P
a d d r e s s
1 8 0 . 2 4 6 . 4 0 . 8 2 .
C o p y r i g h t
A R R S .
F o r
p e r s o n a l
u s e
o n l y ;
a l l
r i g h t s
r e s e r v e d
AJR:203, July 2014 19 CT of the Distal CBD and Ampulla increased enhancement on delayed images, making multiphase protocols extremely use- ful for diagnosis [10, 11]. The periductal inltrating variant can be more difcult to identify; it often presents as asymmetric bile duct wall thickening and en- hancement at the site of transition in the di- lated biliary tree and usually involves only a short segment. These tumors can rarely in- volve a larger segment of the bile duct, some- times extending into the intrahepatic biliary tree, and can rarely be mistaken for an in- ammatory process. In our experience, vol- ume-rendered 3D images have proven to be extremely useful in identifying this variant of cholangiocarcinoma because they nicely accentuate sites of abnormal enhancement and thickening [10] (Figs. 35). Finally, the intraductal variant is quite rare and can have a variable morphology that is not readily distinguishable from the oth- er two morphologic subtypes on CT. These lesions tend to spread along the inner sur- face of the bile duct, either as a supercial- ly spreading mass that presents as focal wall thickening or as a discrete intraluminal poly- ploid mass [10]. Ampullary carcinomaAlthough radiol- ogists often regard the ampulla as a single anatomic entity, it is actually a region com- posed of multiple different structures, the most important of which are the distal CBD, downstream pancreatic duct, and duodenum. Accordingly, this region is composed of sev- eral different types of epithelium, including intestinal epithelium (duodenum), foveolar- like mucosa (papilla of Vater), and pancre- atobiliary epithelium (distal CBD and pan- creatic duct) [12]. As a result, even though ampullary carcinomas are often thought of as a single pathologic entity, in reality they represent a heterogeneous group of tumors arising in the region of the ampulla that can have different biologic behaviors depending on their exact origin. In general, patholo- gists broadly divide these tumors into three groups: tumors arising from the duodenal epithelium of the ampulla, tumors arising from the pancreatobiliary epithelium of the distal CBD or pancreatic duct, and intraam- pullary tumors showing histologic overlap with combined duodenal and pancreaticobil- iary epithelial morphology. These three tumor types can have very different prognoses and biologic behavior. Intraampullary tumors tend to have the best prognosis, which may result from their ori- gin within the ampulla and relatively earlier presentation because of a greater propensi- ty for early, severe ductal obstruction and a lesser invasive component. Alternatively, tu- mors arising from the pancreatobiliary epi- thelium tend to have a worse prognosis, with both histology and prognosis relatively sim- ilar to pancreatic adenocarcinoma. Finally, tumors arising from the duodenal mucosa tend to be large at presentation with a great- er propensity for lymph node metastases but with a prognosis roughly comparable to duo- denal adenocarcinoma [12]. Regardless of this pathologic distinction, these three subtypes cannot be reliably dis- tinguished on any imaging modality includ- ing CT. Kim et al. [13] reported that ampulla- ry carcinomas obstructed both the pancreatic and biliary ducts in 52% of cases and that 48% of cases showed only biliary ductal dil- atation. These results likely reect the differ- ent possible sites of origin for these tumors in the region of the ampulla and are concordant with our experience, which is that isolated dilatation of the pancreatic duct alone is ex- traordinarily rare. The lesion can appear as a discrete nodular mass or as ill-dened soft- tissue thickening near the ampulla. However, in our experience, even if a discrete mass or lesion is not perceptible, careful examination of the ampulla on coronal MPR or 3D im- ages will often show an abrupt margin or ir- regularity at the site of transition in the CBD, which should denitely precipitate further evaluation with ERCP [1315] (Figs. 610). Ampullary carcinoidAlthough ampulla- ry carcinoid tumors are rare, with fewer than 120 cases described in the literature, these neoplasms have an imaging appearance that may allow a more specic diagnosis [16]. In- terestingly, ampullary carcinoids are thought to be biologically distinct from other small- bowel or duodenal carcinoid tumors, with ampullary carcinoids showing a higher pre- dilection for metastatic disease [17]. These tumors tend to present as small lesions, can develop nodal disease even when the pri- mary tumor is quite small, and almost never present with a hypersecretion syndrome [17]. Given the risk of aggressive behavior even with small lesions and their tendency to ob- struct the biliary tree, these tumors invariably are treated with a pancreaticoduodenectomy (Whipple procedure) [18]. Like carcinoid and neuroendocrine tu- mors elsewhere in the bowel or the pancre- as, ampullary carcinoid tumors (and their lo- coregional lymph node metastases) tend to be avidly enhancing on arterial phase imag- es (Fig. 11). Although the exact site of origin of the tumor may be in doubt, the presence of biliary and pancreatic ductal dilatation and a clear fat plane between the mass and the adja- cent pancreatic head should allow the radiol- ogist to prospectively suggest that the tumor arises from the ampulla rather than the pan- creatic head or the adjacent duodenal wall. Pancreatic adenocarcinomaIn some cases, differentiation of a primary pancre- atic head or uncinate process adenocarcino- ma from a primary ampullary neoplasm may be difcult: Both types of lesions can result in biliary and pancreatic ductal obstruction; both tend to be hypoenhancing relative to the normal pancreatic parenchyma; and the ex- act site of origin of a lesion may not be im- mediately evident, particularly with pancre- atic adenocarcinomas primarily centered in the pancreaticoduodenal groove (an anatom- ic space that includes the ampulla) [4, 19]. However, the distinction between the two types of lesions may not be important given that both are treated with pancreaticoduode- nectomy. In our experience, primary ampul- lary lesions, despite their involvement of the pancreatic duct, do not commonly result in upstream pancreatic atrophy, as is often the case with pancreatic adenocarcinoma (Figs. 1214). Moreover, in some cases, a careful appraisal of the images, particularly in the coronal plane, may allow the radiologist to suggest that the lesion is centered in the pan- creatic head rather than the ampulla. Periampullary duodenal carcinomaThe duodenum and proximal jejunum are the most common sites for the development of small- bowel adenocarcinoma, accounting for 50 70% of lesions [19]. When these tumors arise in close proximity to the ampulla, ultimately resulting in biliary and pancreatic ductal ob- struction, the distinction between a prima- ry periampullary duodenal adenocarcinoma and a primary ampullary carcinoma is impos- sible to make based on imaging alone (Fig. 15). Once again, although these lesions arise in very close anatomic proximity, their bio- logic behavior tends to be different: Adsay et al. [12] reported that duodenal adenocarcino- mas were usually less advanced at presenta- tion (i.e., lesser T stage and less likely to har- bor lymph node metastases) than ampullary tumors and that patients with duodenal adeno- carcinomas typically had better survival rates. Benign Causes Distal common bile duct stonesThere is little argument that CT is not the prima- D o w n l o a d e d
f r o m
w w w . a j r o n l i n e . o r g
b y
1 8 0 . 2 4 6 . 4 0 . 8 2
o n
0 7 / 2 4 / 1 4
f r o m
I P
a d d r e s s
1 8 0 . 2 4 6 . 4 0 . 8 2 .
C o p y r i g h t
A R R S .
F o r
p e r s o n a l
u s e
o n l y ;
a l l
r i g h t s
r e s e r v e d
20 AJR:203, July 2014 Raman and Fishman ry diagnostic modality for the identication of stones within either the extrahepatic bile duct or the gallbladder, with both ultrasound and MRI holding clear advantages over CT in both sensitivity and specicity [6]. How- ever, the poor reputation of CT in evaluating biliary stones has almost certainly been exag- gerated by a number of early studies based on older technology that were marred by motion artifact, thick-section acquisitions, and poor spatial and contrast resolution [6]. Depending on their internal composition, stones can be visualized to varying degrees on CT: Highly calcied gallstones can usually be fairly easi- ly identied, often with a rim or crescent of surrounding bile, whereas soft-tissueden- sity stones can be more difcult to visualize [20] (Fig. 16). Thus, visualization of choles- terol stones, which are often isodense to sur- rounding bile, is particularly problematic on CT. Moreover, small stones of soft-tissue density, particularly when impacted at the level of the ampulla, can be almost impos- sible to identify in some cases [21]. As a result, the radiologist must attempt to carefully examine the distal CBD in the setting of biliary obstruction and dilatation, particularly in patients with a known histo- ry of cholecystectomy or gallstones. The use of narrow window settings is vital for iden- tifying subtle soft-tissuedensity stones and the use of multiplanar and curved planar ref- ormations is helpful for tracing the extrahe- patic bile duct inferiorly from the liver hilum to the ampulla [21]. Even if a high-density stone is not identied, a sharp cutoff of a di- lated CBD at the ampulla, often with a well- marginated meniscus conguration, can hint at the presence of an occult stone [21]. Using these primary and secondary signs of choledocholithiasis, several studies have shown CT sensitivities of more than 80%, including at least one study predating the MDCT era [2124] (Figs. 17 and 18). Some practices use unenhanced images in the belief that unenhanced imaging might in- crease the conspicuity of high-density stones in the duct, but there are no data to suggest that dedicated unenhanced images provide any signicant benet in stone detection. Although not widely used in routine clini- cal practice, CT examinations performed at higher tube voltage settings (usually 140 kVp) may increase the conspicuity of stones and, in particular, may increase the attenu- ation and conspicuity of cholesterol stones that are difcult to perceive on standard im- ages [25, 26]. This increased conspicuity of stones at higher tube voltage settings may of- fer a source of potential clinical utility for dual-energy CT as this technology becomes more widely used in practice. Benign biliary stricturesThe list of dif- ferent causes of benign biliary strictures is long and extensive, with the most common causes including prior iatrogenic injuries (most often after cholecystectomy and liv- er transplantation), chronic pancreatitis, and primary sclerosing cholangitis (PSC). Other more rare causes include HIV cholangiopa- thy, unusual infections (including tuberculo- sis) (Fig. 19), Mirizzi syndrome, inammato- ry strictures from certain chemotherapy drugs and other medications, radiation therapy, por- tal biliopathy, and sarcoidosis [2729]. Al- though a detailed discussion of each of these entities is beyond the scope of this article, cer- tain entities are important to consider when dealing with obstruction of the distal CBD, including chronic pancreatitis, PSC, and stric- tures related to HIV cholangiopathy [30]. Chronic pancreatitis can be associated with distal bile duct strictures in up to 46% of patients and jaundice in up to 50% [27]. The presence of stigmata of chronic pancreati- tisincluding pancreatic ductal irregularity and beading, parenchymal and ductal calci- cation, pancreatic pseudocysts, and pancre- atic atrophyin the setting of pancreatic and biliary ductal dilatation should strongly raise the possibility of this diagnosis [27]. How- ever, given that patients with chronic pancre- atitis are at increased risk of developing pan- creatic cancer and the fact that some patients can develop a broinammatory mass at the pancreatic head, the distinction between be- nign and malignant strictures at this site may not be a simple one [3133]. PSC very rarely involves the extrahepat- ic bile duct without abnormalities of the in- trahepatic ducts. As a result, when consid- ering this diagnosis in a patient with a CBD stricture, it is imperative to closely evaluate the intrahepatic ducts for characteristic fea- tures, including beading of the ducts and al- ternating sites of ductal narrowing and dila- tation. Like other types of cholangitis, PSC can be associated with ductal thickening and enhancement, which is usually more diffuse than is commonly seen with malignancy [27] (Fig. 20). However, even in patients with known PSC, abnormal ductal enhancement, thickening, or strictures cannot automatically be assumed to be inammatory given that the lifetime risk of cholangiocarcinoma in PSC patients may be as high as 1030% and up to 0.6% per year [34, 35]. Any new stricture on CT regardless of its appearance or apparently benign features must be considered as suspi- cious and further examined for the presence of malignancy. In particular, CT has proven efcacy in identifying cholangiocarcinoma in the setting of PSC with a sensitivity of 82% and specicity of 80%, which are higher than standard cholangiography [36]. Now increasingly rare given the wide- spread availability of highly active antiret- roviral therapy (HAART), HIV cholangi- opathy can result in strictures of both the intrahepatic and extrahepatic ducts and in papillary stenosis. Depending on the exact ndings, HIV cholangiopathy can mimic the appearance of an obstructing CBD cholan- giocarcinoma, ampullary neoplasm, or in- ammatory cholangitis such as PSC [27, 30]. Imaging alone cannot reliably differentiate a benign from a malignant biliary stricture, although benign strictures are less likely to produce severe proximal biliary dilatation, are usually associated with a lesser degree of bile duct wall thickening and enhancement at the site of transition, and should not be associ- ated with suspicious locoregional lymphade- nopathy or metastatic disease [27]. Moreover, although it can be difcult in many cases, a careful examination of the site of transition in the distal CBD should reveal smooth, ta- pered narrowing rather than an abrupt mar- gin or shouldering [2]. Conclusion In our experience, both the distal CBD and the ampulla are common sites of missed diagnoses for radiologists. Avoiding mis- takes in interpreting imaging ndings in this location requires a systematic approach es- pecially in the setting of unexplained biliary ductal dilatation. Rather than simply sug- gesting that MRCP or ERCP be performed for the ultimate diagnosis, radiologists can perform a careful CT evaluation using mul- tiplanar reformations and 3D imaging to de- termine the correct diagnosis prospectively. A timely and correct diagnosis is imperative because lesions in the ampulla and CBD can be very aggressive despite their small size. References 1. Sugita R, Furuta A, Ito K, Fujita N, Ichinohasama R, Takahashi S. Periampullary tumors: high-spa- tial-resolution MRI imaging and histopathologic ndings in ampullary region specimens. Radiol- ogy 2004; 231:767774 2. Yeh B, Liu P, Soto J, Corvera C, Hussain H. MR D o w n l o a d e d
f r o m
w w w . a j r o n l i n e . o r g
b y
1 8 0 . 2 4 6 . 4 0 . 8 2
o n
0 7 / 2 4 / 1 4
f r o m
I P
a d d r e s s
1 8 0 . 2 4 6 . 4 0 . 8 2 .
C o p y r i g h t
A R R S .
F o r
p e r s o n a l
u s e
o n l y ;
a l l
r i g h t s
r e s e r v e d
AJR:203, July 2014 21 CT of the Distal CBD and Ampulla imaging and CT of the biliary tract. RadioGraph- ics 2009; 29:16691688 3. Pham DT, Hura SA, Willmann JK, Nino-Murcia M, Jeffrey RB Jr. Evaluation of periampullary pa- thology with CT volumetric oblique coronal refor- mations. AJR 2009; 193:[web]W202W208 4. Raman SP, Horton K, Fishman E. Multimodality imaging of pancreatic cancer: computed tomogra- phy, magnetic resonance imaging, and positron emission tomography. Cancer J 2012; 18:511522 5. Raman SP, Horton KM, Fishman EK. Transition- al cell carcinoma of the upper urinary tract: opti- mizing image interpretation with 3D reconstruc- tions. Abdom Imaging 2012; 37:11291140 6. Anderson SW, Zajick D, Lucey BC, Soto JA. 64-detector row computed tomography: an im- proved tool for evaluating the biliary and pancre- atic ducts? Curr Probl Diagn Radiol 2007; 36:258271 7. Salles A, Nino-Murcia M, Jeffrey RB Jr. CT of pancreas: minimum intensity projections. Abdom Imaging 2008; 33:207213 8. Nino-Murcia M, Jeffrey RB Jr, Beaulieu CF, Li KC, Rubin GD. Multidetector CT of the pancreas and bile duct system: value of curved planar refor- mations. AJR 2001; 176:689693 9. Wittekind C, Tannapfel A. Adenoma of the pa- pilla and ampulla: premalignant lesions? Langen- becks Arch Surg 2001; 386:172175 10. Lim J. Cholangiocarcinoma: morphologic classi- cation according to growth pattern and imaging ndings. AJR 2003; 181:819827 11. Choi Y, Lee J, Lee J, et al. Biliary malignancy: value of arterial, pancreatic, and hepatic phase imaging with multidetector-row computed to- mography. J Comput Assist Tomogr 2008; 32:362368 12. Adsay V, Ohike N, Tajiri T, et al. Ampullary re- gion carcinomas: denition and site specic clas- sication with delineation of four clinicopatho- logically and prognostically distinct subsets in an analysis of 249 cases. Am J Surg Pathol 2012; 36:15921608 13. Kim J, Kim M, Chung J, Lee WJ, Yoo H, Lee JT. Differential diagnosis of periampullary carcino- mas at MR imaging. RadioGraphics 2002; 22:13351352 14. Walsh RM, Connelly M, Baker M. Imaging for the diagnosis and staging of periampullary carci- nomas. Surg Endosc 2003; 17:15141520 15. Chang S, Lim JH, Choi D, Kim SK, Lee WJ. Dif- ferentiation of ampullary tumor from benign pap- illary stricture by thin-section multidetector CT. Abdom Imaging 2008; 33:457462 16. Ozsoy M, Ozsoy Y, Canda AE, Nalbant OA, Has- karaca F. The rare malignancy of the hepatobili- ary system: ampullary carcinoid tumor. Case Rep Med 2011; 2011:173036 17. Carter J, Grenert J, Rubernstein L, Stewart L, Lay LW. Neuroendocrine tumors of the ampulla of Vater: biologic behavior and surgical manage- ment. Arch Surg 2009; 144:527531 18. Krishna SG, Lamps LW, Rego RF. Ampullary carcinoid: diagnostic challenges and update on management. Clin Gastroenterol Hepatol 2010; 8:e5e6 19. Hernandez-Jover D, Pernas JC, Gonzalez-Cebal- los S, Lupu I, Monill JM, Perez C. Pancreatoduo- denal junction: review of anatomy and pathologic conditions. J Gastrointest Surg 2011; 15:1269 1281 20. Lalani T, Couto CA, Rosen MP, et al. ACR Ap- propriateness Criteria jaundice. J Am Coll Radiol 2013; 10:402409 21. Anderson SW, Lucey BC, Varghese JC, Soto JA. Accuracy of MDCT in the diagnosis of choledo- cholithiasis. AJR 2006; 187:174180 22. Jeffrey R, Federle M, Laing F, Wall S, Rego J, Moss A. Computed tomography of choledocholi- thiasis. AJR 1983; 140:11791183 23. Tseng CW, Chen CC, Chen TS, Chang FY, Lin HC, Lee SD. Can computed tomography with coronal reconstruction improve the diagnosis of choledocholithiasis? J Gastroenterol Hepatol 2008; 23:15861589 24. Anderson SW, Rho E, Soto J. Detection of biliary duct narrowing and choledocholithiasis: accuracy of portal venous phase multidetector CT. Radiol- ogy 2008; 247:418427 25. Chan WC, Joe BN, Coakley FV, et al. Gallstone detection at CT in vitro: effect of peak voltage set- ting. Radiology 2006; 241:546553 26. Bauer RW, Schulz JR, Zedler B, Graf TG, Vogl TJ. Compound analysis of gallstones using dual energy computed tomography: results in a phan- tom model. Eur J Radiol 2010; 75:e74e80 27. Shanbhogue AK, Tirumani SH, Prasad SR, Fasih N, McInnes M. Benign biliary strictures: a cur- rent comprehensive clinical and imaging review. AJR 2011; 197:[web]W295W306 28. Besa C, Cruz JP, Huete A, Cruz F. Portal biliopa- thy: a multitechnique imaging approach. Abdom Imaging 2012; 37:8390 29. Catalano O, Sahani D, Forcione D, et al. Biliary infections: spectrum of imaging ndings and management. RadioGraphics 2009; 29:2059 2080 30. Tonolini M, Bianco R. HIV-related/AIDS cholan- giopathy: pictorial review with emphasis on MRCP ndings and differential diagnosis. Clin Imaging 2013; 37:219226 31. Edge M, Hoteit M, Patel A, Wang X, Baumgarten D, Cai Q. Clinical signicance of main pancreatic ductal dilatation on computed tomography: single and double duct dilatation. World J Gastroenterol 2007; 13:17011705 32. Menges M, Lerch MM, Zeitz M. The double duct sign in patients with malignant and benign pan- creatic lesions. Gastrointest Endosc 2000; 52:74 77 33. Schlosser W, Siech M, Gorich J, Beger HG. Com- mon bile duct stenosis in complicated chronic pancreatitis. Scand J Gastroenterol 2001; 36:214219 34. Morris-Stiff G, Bhati C, Olliff S, et al. Cholangio- carcinoma complicating primary sclerosing chol- angitis: a 24-year experience. Dig Surg 2008; 25:126132 35. Schulick RD. Primary sclerosing cholangitis: de- tection of cancer in strictures. J Gastrointest Surg 2008; 12:420422 36. Campbell WL, Peterson MS, Federle MP, et al. Using CT and cholangiography to diagnose bili- ary tract carcinoma complicating primary scle- rosing cholangitis. AJR 2001; 177:10951100 (Figures start on next page) D o w n l o a d e d
f r o m
w w w . a j r o n l i n e . o r g
b y
1 8 0 . 2 4 6 . 4 0 . 8 2
o n
0 7 / 2 4 / 1 4
f r o m
I P
a d d r e s s
1 8 0 . 2 4 6 . 4 0 . 8 2 .
C o p y r i g h t
A R R S .
F o r
p e r s o n a l
u s e
o n l y ;
a l l
r i g h t s
r e s e r v e d
22 AJR:203, July 2014 Raman and Fishman A B Fig. 175-year-old man with ampullary mass found at upper endoscopy performed for symptoms of indigestion and reux. A and B, Coronal multiplanar reformation (A) and volume-rendered (B) CT images show discrete mass at ampulla (arrow, A) and only minimal biliary ductal dilatation (B). Mass was ultimately found to be ampullary adenoma. A B Fig. 270-year-old woman with ampullary mass found at endoscopy performed for sensation of chest fullness. A and B, Coronal multiplanar reformation (A) and coronal volume-rendered (B) CT images show polyploid mass (arrows) in periampullary duodenum and no visible ductal dilatation. Mass was found to be ampullary adenoma. D o w n l o a d e d
f r o m
w w w . a j r o n l i n e . o r g
b y
1 8 0 . 2 4 6 . 4 0 . 8 2
o n
0 7 / 2 4 / 1 4
f r o m
I P
a d d r e s s
1 8 0 . 2 4 6 . 4 0 . 8 2 .
C o p y r i g h t
A R R S .
F o r
p e r s o n a l
u s e
o n l y ;
a l l
r i g h t s
r e s e r v e d
AJR:203, July 2014 23 CT of the Distal CBD and Ampulla A Fig. 375-year-old woman who presented with 1-year history of recurrent jaundice. A and B, Coronal volume-rendered CT images show abrupt irregular narrowing and beaking of distal common bile duct (CBD) with irregular enhancement (arrows). This case was found to be distal CBD cholangiocarcinoma. Fig. 475-year-old man who presented with elevated liver enzyme values and bilirubin level during routine ofce visit. Coronal multiplanar reformation CT image shows focal soft tissue (arrow) obstructing mid common bile duct with proximal biliary dilatation and abrupt margin at site of transition. This case was found to be cholangiocarcinoma. Fig. 560-year-old man who presented with elevated liver function test values and abdominal pain. Coronal multiplanar reformation CT image shows diffuse enhancement and wall thickening (arrow) of common bile duct. Intrahepatic ducts (not shown) were not involved. Although inammatory or infectious cholangitis was considered, this case was found to be cholangiocarcinoma. B D o w n l o a d e d
f r o m
w w w . a j r o n l i n e . o r g
b y
1 8 0 . 2 4 6 . 4 0 . 8 2
o n
0 7 / 2 4 / 1 4
f r o m
I P
a d d r e s s
1 8 0 . 2 4 6 . 4 0 . 8 2 .
C o p y r i g h t
A R R S .
F o r
p e r s o n a l
u s e
o n l y ;
a l l
r i g h t s
r e s e r v e d
24 AJR:203, July 2014 Raman and Fishman Fig. 651-year-old woman who presented with weight loss, jaundice, and abdominal pain. Coronal volume-rendered CT image shows markedly dilated intrahepatic and extrahepatic ducts and abrupt beaking (arrow) and narrowing of distal common bile duct. Although no discrete mass was visualized on CT, small ampullary carcinoma was found at endoscopic ultrasound. Fig. 753-year-old man who presented with painless jaundice. Coronal multiplanar reformation CT image shows polyploid mass (arrow) at ampulla obstructing both pancreatic duct and common bile duct. This mass was found to be ampullary carcinoma. A B Fig. 869-year-old man who presented with jaundice and pruritus. A and B, Coronal volume-rendered (A) and multiplanar reformation (B) CT images. Despite presence of stent and poor duodenal distention, images show focal medial duodenal wall thickening (arrows) at level of ampulla, which was ultimately found to be ampullary carcinoma. D o w n l o a d e d
f r o m
w w w . a j r o n l i n e . o r g
b y
1 8 0 . 2 4 6 . 4 0 . 8 2
o n
0 7 / 2 4 / 1 4
f r o m
I P
a d d r e s s
1 8 0 . 2 4 6 . 4 0 . 8 2 .
C o p y r i g h t
A R R S .
F o r
p e r s o n a l
u s e
o n l y ;
a l l
r i g h t s
r e s e r v e d
AJR:203, July 2014 25 CT of the Distal CBD and Ampulla Fig. 969-year-old woman who presented with jaundice and abdominal pain. Coronal volume-rendered CT image shows focal wall thickening (arrows) along medial duodenal wall at level of ampulla, which was ultimately found to be ampullary carcinoma. Fig. 1067-year-old man who presented with jaundice. Coronal volume- rendered CT image shows focal mass (arrow) at ampulla obstructing distal common bile duct (CBD). Distal CBD is abruptly narrowed and irregular. This mass was ultimately found to be ampullary carcinoma. A B Fig. 1149-year-old woman with incidentally discovered biliary dilatation on unenhanced CT performed to exclude renal stones. A and B, Axial (A) and coronal (B) arterial phase multiplanar reformation images show hypervascular mass (white arrows) obstructing distal common bile duct and pancreatic ducts and adjacent hypervascular lymph node metastasis (black arrow, B). Mass was found to be ampullary carcinoid. D o w n l o a d e d
f r o m
w w w . a j r o n l i n e . o r g
b y
1 8 0 . 2 4 6 . 4 0 . 8 2
o n
0 7 / 2 4 / 1 4
f r o m
I P
a d d r e s s
1 8 0 . 2 4 6 . 4 0 . 8 2 .
C o p y r i g h t
A R R S .
F o r
p e r s o n a l
u s e
o n l y ;
a l l
r i g h t s
r e s e r v e d
26 AJR:203, July 2014 Raman and Fishman A C B Fig. 1278-year-old man who presented with jaundice. A and B, Coronal multiplanar reformation (MPR) (A) and volume-rendered (B) CT images show abrupt obstruction of common bile duct by hypodense mass in pancreatic head (arrows). C, Coronal MPR image shows concurrent severe obstruction of pancreatic duct. Mass was found to be pancreatic adenocarcinoma. Fig. 1346-year-old woman who presented with painless jaundice. Coronal minimum-intensity- projection CT image shows markedly dilated common bile duct with abrupt narrowing near ampulla. Morphology of ductal narrowing raised concern even though no discrete mass was identied; this case was found to be small pancreatic adenocarcinoma obstructing duct. Fig. 1475-year-old man who presented with jaundice and abdominal pain. Coronal volume- rendered CT image shows markedly dilated common bile duct with abrupt irregular narrowing distally. Subtle texture change in pancreatic head is seen but no discrete mass. This case was found to be small pancreatic adenocarcinoma. Fig. 1571-year-old man with duodenal mass discovered during upper endoscopy performed for upper gastrointestinal bleeding. Coronal multiplanar reformation CT image shows annular constricting mass (arrows) that extends into ampulla. This mass was judged after surgical resection to be periampullary duodenal adenocarcinoma. D o w n l o a d e d
f r o m
w w w . a j r o n l i n e . o r g
b y
1 8 0 . 2 4 6 . 4 0 . 8 2
o n
0 7 / 2 4 / 1 4
f r o m
I P
a d d r e s s
1 8 0 . 2 4 6 . 4 0 . 8 2 .
C o p y r i g h t
A R R S .
F o r
p e r s o n a l
u s e
o n l y ;
a l l
r i g h t s
r e s e r v e d
AJR:203, July 2014 27 CT of the Distal CBD and Ampulla Fig. 1676-year-old man with known cholelithiasis on prior ultrasound. Axial CT image shows soft- tissuedensity stone (arrow) in distal common bile duct and ampulla with characteristic rim of surrounding bile. Fig. 1784-year-old man with history of gallstones. Coronal volume-rendered CT image shows obstructing stone (arrow) in distal common bile duct and proximal biliary dilatation. Fig. 1891-year-old woman with choledocholithiasis incidentally discovered during evaluation for melanoma. Coronal volume-rendered CT image shows common bile duct stone (arrow) without signicant proximal biliary dilatation. Fig. 1978-year-old woman who presented with fever and jaundice. Coronal volume-rendered CT image shows focal thickening of distal common bile duct (arrows) initially thought to be either pancreatic cancer or ampullary carcinoma. This case was ultimately found to be tuberculosis, and there were multiple other sites of infection elsewhere in body. D o w n l o a d e d
f r o m
w w w . a j r o n l i n e . o r g
b y
1 8 0 . 2 4 6 . 4 0 . 8 2
o n
0 7 / 2 4 / 1 4
f r o m
I P
a d d r e s s
1 8 0 . 2 4 6 . 4 0 . 8 2 .
C o p y r i g h t
A R R S .
F o r
p e r s o n a l
u s e
o n l y ;
a l l
r i g h t s
r e s e r v e d
28 AJR:203, July 2014 Raman and Fishman A B Fig. 2030-year-old man with known primary sclerosing cholangitis. A and B, Axial (A) and coronal (B) CT images show thickening and enhancement of right hepatic duct (arrow, A) and common bile duct (arrow, B); these ndings are suggestive of active bile duct inammation. F O R Y O U R I N F O R M AT I O N This article is available for CME and Self-Assessment (SA-CME) credit that satisfies Part II requirements for maintenance of certification (MOC). To access the examination for this article, follow the prompts associated with the online version of the article. D o w n l o a d e d