Radiographic Exhibit
Diverticulum of the Hepatic Duct: A Rare Anomaly 1
•
sively flattened and atrophic. The wall was fibrous, without a significant amount of smooth muscle. The structure appeared to be a dilated bile duct rather than gallbladder tissue.
Carol Meyers, M.D., Carlos J. Reynes, M.D., and Robert J. Freeark, M.D.
DISCUSSION
A diverticulum of the hepatic duct was found in a 25-year-old woman. Cholangiography revealed that the diverticulum was cystic in nature and contained several stones. Since the intrahepatic ducts are never seen at surgery, the authors stress the importance of preoperative and operative cholangiography in locating such anomalies. INDEX TERMS: Bile Ducts, abnormalities. Bile Ducts, cysts. Bile Ducts, diverticula. Cholangiography, indications
Radiology 119:38, April 1976
• of the bile ducts are uncommon. A particularly rare type of hepatic duct anomaly was found here on intravenous cholangiography.
C
YSTIC MALFORMATIONS
CASE REPORT
In 1964, Jackson and Maxwell (3) reported an intrahepatic diverticulum branching off from the common hepatic duct and described similar cholangiographic findings. In 1959, AIonso-Lej et al. (1) presented a review of 403 cases of various malformations of the bile ducts. Margulis (4) later reported more than 600 such malformations, of which the most common type was choledochal cyst. The true incidence of anomalous hepatic ducts is difficult to assess, since they cannot be seen at operation and many are asymptomatic; however, Eisendrath (2) reported finding such anomalies in 8 % of necropsies. Department of Radiology Loyola University Medical Center 2160 S. First Ave. Maywood, III. 60153
A 25-year-old white woman presented complaining of recurrent bouts of epigastric pain radiating to the right scapular region and back. She had undergone cholecystectomy for stones in 1966. The physical examination was unremarkable. Laboratory findings included an amylase level of 117 units, SGOT 20 units, LDH 30 units, total protein 7.2 g/100 ml, and total bilirubin 0.2 mg/100 ml. Intravenous cholangiography showed a circular collection of radiolucent defects in a pool of contrast material above the cystic duct remnant (Figs. 1 and 2). At surgery, an anomalous duct was found branching off to the right from the right hepatic duct and extending posteriorly, terminating in a bile receptacle. At operation, cholangiography showed the stone-filled cyst and cystic duct remnant (Fig. 3). Microscopic study showed that the cystic structure was lined by bile duct epitheliLim which was exten-
ACKNOWLEDGMENTS: We wish to thank R. Maningo, M.D., and N. Gutierres, M.D., for their assistance.
REFERENCES 1. Alonso-Lej F, Rever WB Jr, Pessagno OJ: Congenital choledochal cyst, with a report of 2, and an analysis of 94, cases. Collective review. lnt Abst Surg 108:1-30, Jan 1959 (in Surg Gynec Obstet 108, Jan 1959). 2. Eisendrath ON: Operative injury of the common and hepatic bile ducts. Surg Gynec Obstet 31:1-18, Jul 1920 3. Jackson FC, Maxwell JW Jr: Intrahepatic diverticulum-common hepatic bile duct. Arch Surg 89:706-708, Oct 1964 4. Margulis AR: Alimentary Tract Roentgenology. St. Louis, Mo., Mosby, 2d Ed, 1973
Fig. 1. Intravenous cholangiogram demonstrates the hepatic duct diverticulum containing contrast material (arrow 1) and being penetrated by an anomalous duct (arrow 2). Fig. 2. Repeat cholangiogram shows the hepatic duct diverticulum (arrow 1) and common hepatic duct (arrow 2). There is contrast material in the cystic duct remnant (arrow 3). Fig. 3. Operative cholangiogram reveals a normal common hepatic duct with filling of the cystic duct remnant and a diverticulum branching off from the right hepatic duct. The contrast material-filled diverticulum corresponds to the collection of contrast material seen on the earlier cholangiogram. 1 From the Departments of Radiology (C.M., Resident; C.J.R., Associate Professor) and Surgery (R.J.F., Chairman), Loyola University Medical Center, Maywood, III. Accepted for publication in November 1975. sjh
38
Diverticulum of the Hepatic Duct: A Rare Anomaly 1
•
sively flattened and atrophic. The wall was fibrous, without a significant amount of smooth muscle. The structure appeared to be a dilated bile duct rather than gallbladder tissue.
Carol Meyers, M.D., Carlos J. Reynes, M.D., and Robert J. Freeark, M.D.
DISCUSSION
A diverticulum of the hepatic duct was found in a 25-year-old woman. Cholangiography revealed that the diverticulum was cystic in nature and contained several stones. Since the intrahepatic ducts are never seen at surgery, the authors stress the importance of preoperative and operative cholangiography in locating such anomalies. INDEX TERMS: Bile Ducts, abnormalities. Bile Ducts, cysts. Bile Ducts, diverticula. Cholangiography, indications
Radiology 119:38, April 1976
• of the bile ducts are uncommon. A particularly rare type of hepatic duct anomaly was found here on intravenous cholangiography.
C
YSTIC MALFORMATIONS
CASE REPORT
In 1964, Jackson and Maxwell (3) reported an intrahepatic diverticulum branching off from the common hepatic duct and described similar cholangiographic findings. In 1959, AIonso-Lej et al. (1) presented a review of 403 cases of various malformations of the bile ducts. Margulis (4) later reported more than 600 such malformations, of which the most common type was choledochal cyst. The true incidence of anomalous hepatic ducts is difficult to assess, since they cannot be seen at operation and many are asymptomatic; however, Eisendrath (2) reported finding such anomalies in 8 % of necropsies. Department of Radiology Loyola University Medical Center 2160 S. First Ave. Maywood, III. 60153
A 25-year-old white woman presented complaining of recurrent bouts of epigastric pain radiating to the right scapular region and back. She had undergone cholecystectomy for stones in 1966. The physical examination was unremarkable. Laboratory findings included an amylase level of 117 units, SGOT 20 units, LDH 30 units, total protein 7.2 g/100 ml, and total bilirubin 0.2 mg/100 ml. Intravenous cholangiography showed a circular collection of radiolucent defects in a pool of contrast material above the cystic duct remnant (Figs. 1 and 2). At surgery, an anomalous duct was found branching off to the right from the right hepatic duct and extending posteriorly, terminating in a bile receptacle. At operation, cholangiography showed the stone-filled cyst and cystic duct remnant (Fig. 3). Microscopic study showed that the cystic structure was lined by bile duct epitheliLim which was exten-
ACKNOWLEDGMENTS: We wish to thank R. Maningo, M.D., and N. Gutierres, M.D., for their assistance.
REFERENCES 1. Alonso-Lej F, Rever WB Jr, Pessagno OJ: Congenital choledochal cyst, with a report of 2, and an analysis of 94, cases. Collective review. lnt Abst Surg 108:1-30, Jan 1959 (in Surg Gynec Obstet 108, Jan 1959). 2. Eisendrath ON: Operative injury of the common and hepatic bile ducts. Surg Gynec Obstet 31:1-18, Jul 1920 3. Jackson FC, Maxwell JW Jr: Intrahepatic diverticulum-common hepatic bile duct. Arch Surg 89:706-708, Oct 1964 4. Margulis AR: Alimentary Tract Roentgenology. St. Louis, Mo., Mosby, 2d Ed, 1973
Fig. 1. Intravenous cholangiogram demonstrates the hepatic duct diverticulum containing contrast material (arrow 1) and being penetrated by an anomalous duct (arrow 2). Fig. 2. Repeat cholangiogram shows the hepatic duct diverticulum (arrow 1) and common hepatic duct (arrow 2). There is contrast material in the cystic duct remnant (arrow 3). Fig. 3. Operative cholangiogram reveals a normal common hepatic duct with filling of the cystic duct remnant and a diverticulum branching off from the right hepatic duct. The contrast material-filled diverticulum corresponds to the collection of contrast material seen on the earlier cholangiogram. 1 From the Departments of Radiology (C.M., Resident; C.J.R., Associate Professor) and Surgery (R.J.F., Chairman), Loyola University Medical Center, Maywood, III. Accepted for publication in November 1975. sjh
38
