Vous êtes sur la page 1sur 12

G a s t r o i n t e s t i n a l I m a g i n g R ev i ew

Raman and Fishman


CT of the Distal CBD and Ampulla

Gastrointestinal Imaging
Review
Abnormalities of the Distal
Common Bile Duct and Ampulla:
Diagnostic Approach and
Differential Diagnosis Using
FOCUS ON:

Multiplanar Reformations and


3D Imaging
Siva P. Raman1 OBJECTIVE. The distal common bile duct (CBD) and ampulla are extremely difficult
Elliot K. Fishman 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,
Raman SP, Fishman EK 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 findings in
American Journal of Roentgenology 2014.203:17-28.

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.

T
he distal common bile duct es will ultimately require either MRCP or
(CBD) and ampulla can be an ERCP for further definitive evaluation, but
extremely challenging location an accurate interpretation of the initial CT
for the radiologist to assess: It examination may allow the radiologist to
can be difficult not only to differentiate a prospectively suggest the correct diagnosis.
normal distal CBD with mild dilatation from
a distal CBD with true pathologic dilatation Evaluation of Biliary Dilatation
but also, even once an abnormality has been In general, the CBD should measure 7 mm
identified, to provide the appropriate differ- or less in healthy patients, although the nor-
ential diagnosis. The accurate radiologic mal duct may be dilated in older patients and
evaluation of this location is of great impor- those who have undergone cholecystectomy.
tance because periampullary tumors are the Thus, overemphasizing CBD measurements,
Keywords: 3D imaging, ampulla, ampullary carcinoma,
common bile duct, CT, pancreatic adenocarcinoma
third most common type of gastrointestinal especially when the ducts are only mildly di-
neoplasm, after colonic and gastric tumors, lated, should be avoided, particularly in pa-
DOI:10.2214/AJR.13.11288 and because the different lesions found in tients without symptoms (i.e., biliary colic,
this location can have markedly different right upper quadrant pain, jaundice) or bio-
Received May 24, 2013; accepted after revision
prognoses [1]. chemical markers suggestive of biliary ob-
July 2, 2013.
This article seeks to provide the reader struction [2]. In patients with borderline en-
1
Both authors: Department of Radiology, Johns Hopkins with a framework for interpreting CT stud- largement of the ducts without CT evidence
University, 601 N Caroline St, JHOC 3251, Baltimore, MD ies of the distal CBD and ampulla, including of a discrete obstructing mass or other sus-
21287. Address correspondence to S. P. Raman providing a differential diagnosis for ampul- picious imaging features, the best course of
(srsraman3@gmail.com).
lary and distal CBD abnormalities and le- action may be to simply recommend corre-
This article is available for credit. sions, a perspective on when a dilated CBD lation with clinical and biochemical mark-
requires further evaluation with MRCP or ers of obstruction rather than recommending
AJR 2014; 203:1728 ERCP, and a discussion of the use of multi- MRCP or ERCP in every patient.
0361803X/14/203117
planar reformations (MPRs) and 3D imaging Normal bile ducts on CT should have an
to better assess the morphology of the dis- almost imperceptible wall ( 1 mm), with
American Roentgen Ray Society tal CBD and ampulla. Of course, many cas- only minimal enhancement on either arteri-

AJR:203, July 2014 17


Raman and Fishman

al or venous phase images. In the setting of before scanning to maximize gastric and du- pared with those of the large bowel, and
dilated bile ducts, the ducts must be carefully odenal distention [4]. within the small bowel, adenomas are more
evaluated for the presence of focal or diffuse After the acquisition of source axial imag- common in the ileum and jejunum than in
hyperenhancement on arterial or venous phase es and reconstruction of standard MPRs, we the duodenum. Within the duodenum, 10%
images; delayed enhancement, if delayed im- have found three image postprocessing re- of all duodenal polyps are ultimately found
ages are acquired; focal or diffuse bile duct construction algorithms (including 3D post- to be adenomas, and the most common loca-
wall thickening; and a discrete mass. processing) to be the most useful for image tion is in proximity to the ampulla of Vater
The same precepts traditionally used to interpretation: volume rendering (VR), min- [9]. These lesions are most common in elder-
analyze the bile ducts on ERCP are just as imum intensity projections, and curved pla- ly patients, and other than familial adenoma-
important to apply to CT as well: The CBD nar reformations. VR is a complex, compu- tosis coli, no other clear risk factors for the
should be carefully evaluated for discrete tationally intensive computer algorithm that development of ampullary adenomas have
sites of transition between dilated proximal assigns a specific color and transparency to been described in the literature [9].
ducts and a decompressed or narrowed dis- each voxel in a dataset on the basis of its at- Ampullary adenomas are benign lesions
tal duct. Once a site of transition is found, tenuation and relationship to other adjacent that retain malignant potential: Similar to
any evidence of irregularity, abrupt narrow- voxels before presenting these data in a 3D the adenoma-carcinoma sequence in the co-
ing, or shouldering at the transition point display. The VR technique allows the best lon, these lesions usually contain foci of low-
should raise suspicion for malignancy. Al- soft-tissue definition of any of the 3D re- grade dysplasia and have the potential to de-
though this evaluation can be performed construction tools and is a vital component velop higher-grade dysplasia and invasive
using the source axial images, the use of of biliary analysis. This technique is useful carcinoma, particularly as they grow larger.
coronal and sagittal MPR images and 3D re- not only for increasing the conspicuity of ob- Up to 60% of ampullary adenomas are ul-
constructions can be vital [3]. structing lesions, but also for increasing the timately found to harbor at least some foci
conspicuity of subtle biliary hyperenhance- of invasive carcinoma (especially in large
American Journal of Roentgenology 2014.203:17-28.

Technique ment and thickening [4, 5]. lesions), so the preoperative distinction be-
In any patient with a suspected pancreato- Minimum-intensity-projection reconstruc- tween an adenoma and an ampullary carci-
biliary abnormality, a dual-phase study with tions rely on the same principles as maxi- noma is not relevant for the radiologist [9].
both arterial and venous phase images should mum-intensity-projection (MIP) imaging. There are no dedicated descriptions of the
be acquired. The arterial phase images are used However, unlike MIP reconstructions, which imaging appearance of ampullary adenomas
to identify hypervascular tumors (i.e., ampul- project the highest-attenuation voxels in a da- in the literature to date; in our experience,
lary carcinoid, pancreatic neuroendocrine tu- taset, minimum-intensity-projection recon- although ampullary adenomas may have a
mors, hypervascular gastrointestinal stromal structions project the lowest-attenuation vox- slightly lesser predilection for causing severe
tumors), subtle biliary tree mucosal hyperen- els, making them extraordinarily valuable for ductal obstruction, their CT appearance is
hancement and thickening, and tumor neovas- visualization of fluid-filled structures, such as not significantly different from that of am-
cularity and to evaluate the arterial anatomy the biliary tree or pancreatic duct, particularly pullary carcinomas (Figs. 1 and 2).
before surgery. The venous phase images are when these structures are dilated or obstruct- CholangiocarcinomaAlthough cholangio
used to evaluate the liver and pancreas for tra- ed. At our institution, although MIP images carcinomas of the extrahepatic duct have
ditionally hypovascular tumors and metasta- are not a major component of biliary tree 3D a strong predilection for the proximal one
ses, locoregional lymphadenopathy, and in- analysis, minimum-intensity-projection re- third of the duct, up to 20% of lesions oc-
volvement of the venous vasculature by tumor constructions are performed in every case, and cur in the distal one third and 95% of pa-
[4]. Although delayed images are not routinely we have experienced great success in identify- tients show ductal obstruction at the time
acquired, they may be added to the protocol if ing small tumors that were more conspicuous of diagnosis [10]. Traditionally, both intra-
cholangiocarcinoma is prospectively thought when using this imaging technique [6, 7]. hepatic and extrahepatic cholangiocarcino-
to be a diagnostic consideration. Finally, given that the entire extrahepatic mas have been classified into three different
Positive oral contrast material absolutely bile duct does not normally course in the cor- morphologic subtypes, each of which pres-
must be avoided in patients presenting with onal, sagittal, or axial plane, visualizing the ents with a different appearance on imaging:
jaundice or a suspected mass in the pancre- entire duct on any given MPR or the source mass-forming cholangiocarcinoma, periduc-
as, ampulla, or duodenum: Not only will the axial images can be impossible, making it tal infiltrating cholangiocarcinoma, and in-
positive contrast agent obscure any intralu- more difficult to perceive sites of subtle wall traductal cholangiocarcinoma.
minal mass in the duodenum or near the am- thickening or even a discrete mass. Curved The mass-forming cholangiocarcinoma
pulla, but also streak artifact from the con- planar reformations, which are interactively is the easiest of the three subtypes to diag-
trast agent will make evaluation of subtle created by the user as he or she identifies the nose: It usually presents as a discrete mass
duodenal wall thickening or hyperenhance- course of the duct, allow the entire CBD to or nodule that obstructs the extrahepatic bile
ment near the ampulla difficult to perceive be displayed in a single 2D image and are duct. This mass does not have to be partic-
and can interfere with 3D postprocessing al- part of our routine evaluation [6, 8]. ularly large to obstruct the duct, and both
gorithms. Instead, a neutral contrast agent the source axial images and coronal MPRs
such as water or a barium suspension (VoL- Differential Diagnosis should be scrutinized for evidence of a dis-
umen, Bracco Diagnostics) should be used, Malignant Causes crete nodule. Like intrahepatic cholangio-
and some portion of this contrast medium Ampullary adenomaAdenomas of the carcinoma, these lesions can show some hy-
should be given to the patient immediately small bowel are relatively uncommon com- pervascularity on arterial phase images and

18 AJR:203, July 2014


CT of the Distal CBD and Ampulla

increased enhancement on delayed images, presentation because of a greater propensi- es (Fig. 11). Although the exact site of origin
making multiphase protocols extremely use- ty for early, severe ductal obstruction and a of the tumor may be in doubt, the presence of
ful for diagnosis [10, 11]. lesser invasive component. Alternatively, tu- biliary and pancreatic ductal dilatation and a
The periductal infiltrating variant can be mors arising from the pancreatobiliary epi- clear fat plane between the mass and the adja-
more difficult to identify; it often presents as thelium tend to have a worse prognosis, with cent pancreatic head should allow the radiol-
asymmetric bile duct wall thickening and en- both histology and prognosis relatively sim- ogist to prospectively suggest that the tumor
hancement at the site of transition in the di- ilar to pancreatic adenocarcinoma. Finally, arises from the ampulla rather than the pan-
lated biliary tree and usually involves only a tumors arising from the duodenal mucosa creatic head or the adjacent duodenal wall.
short segment. These tumors can rarely in- tend to be large at presentation with a great- Pancreatic adenocarcinomaIn some
volve a larger segment of the bile duct, some- er propensity for lymph node metastases but cases, differentiation of a primary pancre-
times extending into the intrahepatic biliary with a prognosis roughly comparable to duo- atic head or uncinate process adenocarcino-
tree, and can rarely be mistaken for an in- denal adenocarcinoma [12]. ma from a primary ampullary neoplasm may
flammatory process. In our experience, vol- Regardless of this pathologic distinction, be difficult: Both types of lesions can result
ume-rendered 3D images have proven to be these three subtypes cannot be reliably dis- in biliary and pancreatic ductal obstruction;
extremely useful in identifying this variant tinguished on any imaging modality includ- both tend to be hypoenhancing relative to the
of cholangiocarcinoma because they nicely ing CT. Kim et al. [13] reported that ampulla- normal pancreatic parenchyma; and the ex-
accentuate sites of abnormal enhancement ry carcinomas obstructed both the pancreatic act site of origin of a lesion may not be im-
and thickening [10] (Figs. 35). and biliary ducts in 52% of cases and that mediately evident, particularly with pancre-
Finally, the intraductal variant is quite 48% of cases showed only biliary ductal dil- atic adenocarcinomas primarily centered in
rare and can have a variable morphology that atation. These results likely reflect the differ- the pancreaticoduodenal groove (an anatom-
is not readily distinguishable from the oth- ent possible sites of origin for these tumors in ic space that includes the ampulla) [4, 19].
er two morphologic subtypes on CT. These the region of the ampulla and are concordant However, the distinction between the two
American Journal of Roentgenology 2014.203:17-28.

lesions tend to spread along the inner sur- with our experience, which is that isolated types of lesions may not be important given
face of the bile duct, either as a superficial- dilatation of the pancreatic duct alone is ex- that both are treated with pancreaticoduode-
ly spreading mass that presents as focal wall traordinarily rare. The lesion can appear as a nectomy. In our experience, primary ampul-
thickening or as a discrete intraluminal poly- discrete nodular mass or as ill-defined soft- lary lesions, despite their involvement of the
ploid mass [10]. tissue thickening near the ampulla. However, pancreatic duct, do not commonly result in
Ampullary carcinomaAlthough radiol- in our experience, even if a discrete mass or upstream pancreatic atrophy, as is often the
ogists often regard the ampulla as a single lesion is not perceptible, careful examination case with pancreatic adenocarcinoma (Figs.
anatomic entity, it is actually a region com- of the ampulla on coronal MPR or 3D im- 1214). Moreover, in some cases, a careful
posed of multiple different structures, the ages will often show an abrupt margin or ir- appraisal of the images, particularly in the
most important of which are the distal CBD, regularity at the site of transition in the CBD, coronal plane, may allow the radiologist to
downstream pancreatic duct, and duodenum. which should definitely precipitate further suggest that the lesion is centered in the pan-
Accordingly, this region is composed of sev- evaluation with ERCP [1315] (Figs. 610). creatic head rather than the ampulla.
eral different types of epithelium, including Ampullary carcinoidAlthough ampulla- Periampullary duodenal carcinomaThe
intestinal epithelium (duodenum), foveolar- ry carcinoid tumors are rare, with fewer than duodenum and proximal jejunum are the most
like mucosa (papilla of Vater), and pancre- 120 cases described in the literature, these common sites for the development of small-
atobiliary epithelium (distal CBD and pan- neoplasms have an imaging appearance that bowel adenocarcinoma, accounting for 50
creatic duct) [12]. As a result, even though may allow a more specific diagnosis [16]. In- 70% of lesions [19]. When these tumors arise
ampullary carcinomas are often thought of terestingly, ampullary carcinoids are thought in close proximity to the ampulla, ultimately
as a single pathologic entity, in reality they to be biologically distinct from other small- resulting in biliary and pancreatic ductal ob-
represent a heterogeneous group of tumors bowel or duodenal carcinoid tumors, with struction, the distinction between a prima-
arising in the region of the ampulla that can ampullary carcinoids showing a higher pre- ry periampullary duodenal adenocarcinoma
have different biologic behaviors depending dilection for metastatic disease [17]. These and a primary ampullary carcinoma is impos-
on their exact origin. In general, patholo- tumors tend to present as small lesions, can sible to make based on imaging alone (Fig.
gists broadly divide these tumors into three develop nodal disease even when the pri- 15). Once again, although these lesions arise
groups: tumors arising from the duodenal mary tumor is quite small, and almost never in very close anatomic proximity, their bio-
epithelium of the ampulla, tumors arising present with a hypersecretion syndrome [17]. logic behavior tends to be different: Adsay et
from the pancreatobiliary epithelium of the Given the risk of aggressive behavior even al. [12] reported that duodenal adenocarcino-
distal CBD or pancreatic duct, and intraam- with small lesions and their tendency to ob- mas were usually less advanced at presenta-
pullary tumors showing histologic overlap struct the biliary tree, these tumors invariably tion (i.e., lesser T stage and less likely to har-
with combined duodenal and pancreaticobil- are treated with a pancreaticoduodenectomy bor lymph node metastases) than ampullary
iary epithelial morphology. (Whipple procedure) [18]. tumors and that patients with duodenal adeno-
These three tumor types can have very Like carcinoid and neuroendocrine tu- carcinomas typically had better survival rates.
different prognoses and biologic behavior. mors elsewhere in the bowel or the pancre-
Intraampullary tumors tend to have the best as, ampullary carcinoid tumors (and their lo- Benign Causes
prognosis, which may result from their ori- coregional lymph node metastases) tend to Distal common bile duct stonesThere
gin within the ampulla and relatively earlier be avidly enhancing on arterial phase imag- is little argument that CT is not the prima-

AJR:203, July 2014 19


Raman and Fishman

ry diagnostic modality for the identification stones at higher tube voltage settings may of- 0.6% per year [34, 35]. Any new stricture on
of stones within either the extrahepatic bile fer a source of potential clinical utility for CT regardless of its appearance or apparently
duct or the gallbladder, with both ultrasound dual-energy CT as this technology becomes benign features must be considered as suspi-
and MRI holding clear advantages over CT more widely used in practice. cious and further examined for the presence
in both sensitivity and specificity [6]. How- Benign biliary stricturesThe list of dif- of malignancy. In particular, CT has proven
ever, the poor reputation of CT in evaluating ferent causes of benign biliary strictures is efficacy in identifying cholangiocarcinoma
biliary stones has almost certainly been exag- long and extensive, with the most common in the setting of PSC with a sensitivity of 82%
gerated by a number of early studies based on causes including prior iatrogenic injuries and specificity of 80%, which are higher than
older technology that were marred by motion (most often after cholecystectomy and liv- standard cholangiography [36].
artifact, thick-section acquisitions, and poor er transplantation), chronic pancreatitis, and Now increasingly rare given the wide-
spatial and contrast resolution [6]. Depending primary sclerosing cholangitis (PSC). Other spread availability of highly active antiret-
on their internal composition, stones can be more rare causes include HIV cholangiopa- roviral therapy (HAART), HIV cholangi-
visualized to varying degrees on CT: Highly thy, unusual infections (including tuberculo- opathy can result in strictures of both the
calcified gallstones can usually be fairly easi- sis) (Fig. 19), Mirizzi syndrome, inflammato- intrahepatic and extrahepatic ducts and in
ly identified, often with a rim or crescent ry strictures from certain chemotherapy drugs papillary stenosis. Depending on the exact
of surrounding bile, whereas soft-tissueden- and other medications, radiation therapy, por- findings, HIV cholangiopathy can mimic the
sity stones can be more difficult to visualize tal biliopathy, and sarcoidosis [2729]. Al- appearance of an obstructing CBD cholan-
[20] (Fig. 16). Thus, visualization of choles- though a detailed discussion of each of these giocarcinoma, ampullary neoplasm, or in-
terol stones, which are often isodense to sur- entities is beyond the scope of this article, cer- flammatory cholangitis such as PSC [27, 30].
rounding bile, is particularly problematic on tain entities are important to consider when Imaging alone cannot reliably differentiate
CT. Moreover, small stones of soft-tissue dealing with obstruction of the distal CBD, a benign from a malignant biliary stricture,
density, particularly when impacted at the including chronic pancreatitis, PSC, and stric- although benign strictures are less likely to
American Journal of Roentgenology 2014.203:17-28.

level of the ampulla, can be almost impos- tures related to HIV cholangiopathy [30]. produce severe proximal biliary dilatation,
sible to identify in some cases [21]. Chronic pancreatitis can be associated are usually associated with a lesser degree of
As a result, the radiologist must attempt with distal bile duct strictures in up to 46% of bile duct wall thickening and enhancement at
to carefully examine the distal CBD in the patients and jaundice in up to 50% [27]. The the site of transition, and should not be associ-
setting of biliary obstruction and dilatation, presence of stigmata of chronic pancreati- ated with suspicious locoregional lymphade-
particularly in patients with a known histo- tisincluding pancreatic ductal irregularity nopathy or metastatic disease [27]. Moreover,
ry of cholecystectomy or gallstones. The use and beading, parenchymal and ductal calci- although it can be difficult in many cases, a
of narrow window settings is vital for iden- fication, pancreatic pseudocysts, and pancre- careful examination of the site of transition
tifying subtle soft-tissuedensity stones and atic atrophyin the setting of pancreatic and in the distal CBD should reveal smooth, ta-
the use of multiplanar and curved planar ref- biliary ductal dilatation should strongly raise pered narrowing rather than an abrupt mar-
ormations is helpful for tracing the extrahe- the possibility of this diagnosis [27]. How- gin or shouldering [2].
patic bile duct inferiorly from the liver hilum ever, given that patients with chronic pancre-
to the ampulla [21]. Even if a high-density atitis are at increased risk of developing pan- Conclusion
stone is not identified, a sharp cutoff of a di- creatic cancer and the fact that some patients In our experience, both the distal CBD
lated CBD at the ampulla, often with a well- can develop a fibroinflammatory mass at the and the ampulla are common sites of missed
marginated meniscus configuration, can pancreatic head, the distinction between be- diagnoses for radiologists. Avoiding mis-
hint at the presence of an occult stone [21]. nign and malignant strictures at this site may takes in interpreting imaging findings in this
Using these primary and secondary signs not be a simple one [3133]. location requires a systematic approach es-
of choledocholithiasis, several studies have PSC very rarely involves the extrahepat- pecially in the setting of unexplained biliary
shown CT sensitivities of more than 80%, ic bile duct without abnormalities of the in- ductal dilatation. Rather than simply sug-
including at least one study predating the trahepatic ducts. As a result, when consid- gesting that MRCP or ERCP be performed
MDCT era [2124] (Figs. 17 and 18). ering this diagnosis in a patient with a CBD for the ultimate diagnosis, radiologists can
Some practices use unenhanced images in stricture, it is imperative to closely evaluate perform a careful CT evaluation using mul-
the belief that unenhanced imaging might in- the intrahepatic ducts for characteristic fea- tiplanar reformations and 3D imaging to de-
crease the conspicuity of high-density stones tures, including beading of the ducts and al- termine the correct diagnosis prospectively.
in the duct, but there are no data to suggest ternating sites of ductal narrowing and dila- A timely and correct diagnosis is imperative
that dedicated unenhanced images provide tation. Like other types of cholangitis, PSC because lesions in the ampulla and CBD can
any significant benefit in stone detection. can be associated with ductal thickening and be very aggressive despite their small size.
Although not widely used in routine clini- enhancement, which is usually more diffuse
cal practice, CT examinations performed than is commonly seen with malignancy [27] References
at higher tube voltage settings (usually 140 (Fig. 20). However, even in patients with 1. Sugita R, Furuta A, Ito K, Fujita N, Ichinohasama
kVp) may increase the conspicuity of stones known PSC, abnormal ductal enhancement, R, Takahashi S. Periampullary tumors: high-spa-
and, in particular, may increase the attenu- thickening, or strictures cannot automatically tial-resolution MRI imaging and histopathologic
ation and conspicuity of cholesterol stones be assumed to be inflammatory given that the findings in ampullary region specimens. Radiol-
that are difficult to perceive on standard im- lifetime risk of cholangiocarcinoma in PSC ogy 2004; 231:767774
ages [25, 26]. This increased conspicuity of patients may be as high as 1030% and up to 2. Yeh B, Liu P, Soto J, Corvera C, Hussain H. MR

20 AJR:203, July 2014


CT of the Distal CBD and Ampulla

imaging and CT of the biliary tract. RadioGraph- mas at MR imaging. RadioGraphics 2002; detection at CT in vitro: effect of peak voltage set-
ics 2009; 29:16691688 22:13351352 ting. Radiology 2006; 241:546553
3. Pham DT, Hura SA, Willmann JK, Nino-Murcia 14. Walsh RM, Connelly M, Baker M. Imaging for 26. Bauer RW, Schulz JR, Zedler B, Graf TG, Vogl
M, Jeffrey RB Jr. Evaluation of periampullary pa- the diagnosis and staging of periampullary carci- TJ. Compound analysis of gallstones using dual
thology with CT volumetric oblique coronal refor- nomas. Surg Endosc 2003; 17:15141520 energy computed tomography: results in a phan-
mations. AJR 2009; 193:[web]W202W208 15. Chang S, Lim JH, Choi D, Kim SK, Lee WJ. Dif- tom model. Eur J Radiol 2010; 75:e74e80
4. Raman SP, Horton K, Fishman E. Multimodality ferentiation of ampullary tumor from benign pap- 27. Shanbhogue AK, Tirumani SH, Prasad SR, Fasih
imaging of pancreatic cancer: computed tomogra- illary stricture by thin-section multidetector CT. N, McInnes M. Benign biliary strictures: a cur-
phy, magnetic resonance imaging, and positron Abdom Imaging 2008; 33:457462 rent comprehensive clinical and imaging review.
emission tomography. Cancer J 2012; 18:511522 16. Ozsoy M, Ozsoy Y, Canda AE, Nalbant OA, Has- AJR 2011; 197:[web]W295W306
5. Raman SP, Horton KM, Fishman EK. Transition- karaca F. The rare malignancy of the hepatobili- 28. Besa C, Cruz JP, Huete A, Cruz F. Portal biliopa-
al cell carcinoma of the upper urinary tract: opti- ary system: ampullary carcinoid tumor. Case Rep thy: a multitechnique imaging approach. Abdom
mizing image interpretation with 3D reconstruc- Med 2011; 2011:173036 Imaging 2012; 37:8390
tions. Abdom Imaging 2012; 37:11291140 17. Carter J, Grenert J, Rubernstein L, Stewart L, Lay 29. Catalano O, Sahani D, Forcione D, et al. Biliary
6. Anderson SW, Zajick D, Lucey BC, Soto JA. LW. Neuroendocrine tumors of the ampulla of infections: spectrum of imaging findings and
64-detector row computed tomography: an im- Vater: biologic behavior and surgical manage- management. RadioGraphics 2009; 29:2059
proved tool for evaluating the biliary and pancre- ment. Arch Surg 2009; 144:527531 2080
atic ducts? Curr Probl Diagn Radiol 2007; 18. Krishna SG, Lamps LW, Rego RF. Ampullary 30. Tonolini M, Bianco R. HIV-related/AIDS cholan-
36:258271 carcinoid: diagnostic challenges and update on giopathy: pictorial review with emphasis on
7. Salles A, Nino-Murcia M, Jeffrey RB Jr. CT of management. Clin Gastroenterol Hepatol 2010; MRCP findings and differential diagnosis. Clin
pancreas: minimum intensity projections. Abdom 8:e5e6 Imaging 2013; 37:219226
Imaging 2008; 33:207213 19. Hernandez-Jover D, Pernas JC, Gonzalez-Cebal- 31. Edge M, Hoteit M, Patel A, Wang X, Baumgarten
American Journal of Roentgenology 2014.203:17-28.

8. Nino-Murcia M, Jeffrey RB Jr, Beaulieu CF, Li los S, Lupu I, Monill JM, Perez C. Pancreatoduo- D, Cai Q. Clinical significance of main pancreatic
KC, Rubin GD. Multidetector CT of the pancreas denal junction: review of anatomy and pathologic ductal dilatation on computed tomography: single
and bile duct system: value of curved planar refor- conditions. J Gastrointest Surg 2011; 15:1269 and double duct dilatation. World J Gastroenterol
mations. AJR 2001; 176:689693 1281 2007; 13:17011705
9. Wittekind C, Tannapfel A. Adenoma of the pa- 20. Lalani T, Couto CA, Rosen MP, et al. ACR Ap- 32. Menges M, Lerch MM, Zeitz M. The double duct
pilla and ampulla: premalignant lesions? Langen- propriateness Criteria jaundice. J Am Coll Radiol sign in patients with malignant and benign pan-
becks Arch Surg 2001; 386:172175 2013; 10:402409 creatic lesions. Gastrointest Endosc 2000; 52:74
10. Lim J. Cholangiocarcinoma: morphologic classi- 21. Anderson SW, Lucey BC, Varghese JC, Soto JA. 77
fication according to growth pattern and imaging Accuracy of MDCT in the diagnosis of choledo- 33. Schlosser W, Siech M, Gorich J, Beger HG. Com-
findings. AJR 2003; 181:819827 cholithiasis. AJR 2006; 187:174180 mon bile duct stenosis in complicated chronic
11. Choi Y, Lee J, Lee J, et al. Biliary malignancy: 22. Jeffrey R, Federle M, Laing F, Wall S, Rego J, pancreatitis. Scand J Gastroenterol 2001;
value of arterial, pancreatic, and hepatic phase Moss A. Computed tomography of choledocholi- 36:214219
imaging with multidetector-row computed to- thiasis. AJR 1983; 140:11791183 34. Morris-Stiff G, Bhati C, Olliff S, et al. Cholangio-
mography. J Comput Assist Tomogr 2008; 23. Tseng CW, Chen CC, Chen TS, Chang FY, Lin carcinoma complicating primary sclerosing chol-
32:362368 HC, Lee SD. Can computed tomography with angitis: a 24-year experience. Dig Surg 2008;
12. Adsay V, Ohike N, Tajiri T, et al. Ampullary re- coronal reconstruction improve the diagnosis of 25:126132
gion carcinomas: definition and site specific clas- choledocholithiasis? J Gastroenterol Hepatol 35. Schulick RD. Primary sclerosing cholangitis: de-
sification with delineation of four clinicopatho- 2008; 23:15861589 tection of cancer in strictures. J Gastrointest Surg
logically and prognostically distinct subsets in an 24. Anderson SW, Rho E, Soto J. Detection of biliary 2008; 12:420422
analysis of 249 cases. Am J Surg Pathol 2012; duct narrowing and choledocholithiasis: accuracy 36. Campbell WL, Peterson MS, Federle MP, et al.
36:15921608 of portal venous phase multidetector CT. Radiol- Using CT and cholangiography to diagnose bili-
13. Kim J, Kim M, Chung J, Lee WJ, Yoo H, Lee JT. ogy 2008; 247:418427 ary tract carcinoma complicating primary scle-
Differential diagnosis of periampullary carcino- 25. Chan WC, Joe BN, Coakley FV, et al. Gallstone rosing cholangitis. AJR 2001; 177:10951100

(Figures start on next page)

AJR:203, July 2014 21


Raman and Fishman

A B

Fig. 175-year-old man with ampullary mass found at upper endoscopy performed for symptoms of indigestion and reflux.
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).
American Journal of Roentgenology 2014.203:17-28.

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.

22 AJR:203, July 2014


CT of the Distal CBD and Ampulla

A B

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.
American Journal of Roentgenology 2014.203:17-28.

Fig. 475-year-old man who presented with elevated liver enzyme values and Fig. 560-year-old man who presented with elevated liver function test values
bilirubin level during routine office visit. Coronal multiplanar reformation CT image and abdominal pain. Coronal multiplanar reformation CT image shows diffuse
shows focal soft tissue (arrow) obstructing mid common bile duct with proximal enhancement and wall thickening (arrow) of common bile duct. Intrahepatic ducts
biliary dilatation and abrupt margin at site of transition. This case was found to be (not shown) were not involved. Although inflammatory or infectious cholangitis
cholangiocarcinoma. was considered, this case was found to be cholangiocarcinoma.

AJR:203, July 2014 23


Raman and Fishman

Fig. 651-year-old woman who presented with Fig. 753-year-old man who presented with painless
weight loss, jaundice, and abdominal pain. Coronal jaundice. Coronal multiplanar reformation CT image
volume-rendered CT image shows markedly dilated shows polyploid mass (arrow) at ampulla obstructing
intrahepatic and extrahepatic ducts and abrupt both pancreatic duct and common bile duct. This
beaking (arrow) and narrowing of distal common mass was found to be ampullary carcinoma.
bile duct. Although no discrete mass was visualized
on CT, small ampullary carcinoma was found at
endoscopic ultrasound.
American Journal of Roentgenology 2014.203:17-28.

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.

24 AJR:203, July 2014


CT of the Distal CBD and Ampulla

Fig. 969-year-old woman who presented with jaundice and abdominal pain. Fig. 1067-year-old man who presented with jaundice. Coronal volume-
Coronal volume-rendered CT image shows focal wall thickening (arrows) along rendered CT image shows focal mass (arrow) at ampulla obstructing distal
medial duodenal wall at level of ampulla, which was ultimately found to be common bile duct (CBD). Distal CBD is abruptly narrowed and irregular. This
ampullary carcinoma. mass was ultimately found to be ampullary carcinoma.
American Journal of Roentgenology 2014.203:17-28.

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.

AJR:203, July 2014 25


Raman and Fishman

A B C

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.
American Journal of Roentgenology 2014.203:17-28.

Fig. 1346-year-old woman who presented with Fig. 1475-year-old man who presented with Fig. 1571-year-old man with duodenal mass
painless jaundice. Coronal minimum-intensity- jaundice and abdominal pain. Coronal volume- discovered during upper endoscopy performed for
projection CT image shows markedly dilated common rendered CT image shows markedly dilated common upper gastrointestinal bleeding. Coronal multiplanar
bile duct with abrupt narrowing near ampulla. bile duct with abrupt irregular narrowing distally. reformation CT image shows annular constricting
Morphology of ductal narrowing raised concern even Subtle texture change in pancreatic head is seen but mass (arrows) that extends into ampulla. This
though no discrete mass was identified; this case no discrete mass. This case was found to be small mass was judged after surgical resection to be
was found to be small pancreatic adenocarcinoma pancreatic adenocarcinoma. periampullary duodenal adenocarcinoma.
obstructing duct.

26 AJR:203, July 2014


CT of the Distal CBD and Ampulla

Fig. 1676-year-old man with known cholelithiasis Fig. 1784-year-old man with history of gallstones. Fig. 1891-year-old woman with choledocholithiasis
on prior ultrasound. Axial CT image shows soft- Coronal volume-rendered CT image shows incidentally discovered during evaluation for
tissuedensity stone (arrow) in distal common obstructing stone (arrow) in distal common bile duct melanoma. Coronal volume-rendered CT image
bile duct and ampulla with characteristic rim of and proximal biliary dilatation. shows common bile duct stone (arrow) without
surrounding bile. significant proximal biliary dilatation.
American Journal of Roentgenology 2014.203:17-28.

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.

AJR:203, July 2014 27


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
findings are suggestive of active bile duct inflammation.
American Journal of Roentgenology 2014.203:17-28.

F O R YO 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.

28 AJR:203, July 2014