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233

Medial Indentation of the Duodenal Sweep by Common Bile Duct Dilatation

Richard

Palmer

Gold1

The dilated common bile duct has long been recognized as a cause for a smooth, tubular impression across the duodenal bulb or immediate postbulbar duodenum. Only scattered references suggest that a smooth indentation on the medial aspect of the descending duodenum might also be due to an enlarged, tortuous common duct. Three cases of this condition are reported. The dilated common duct impression can mimic a pancreatic mass. While computed tomography, ultrasonography, or transhepatic cholangiography readily suggest the true diagnosis, potential pitfalls in patient management are possible when the first radiographic procedure is an upper gastrointestinal series.

[1,

Compression 2], as has

of the duodenal sweep the tubular impression

postbulbar duodenum by a dilated mented is the compression of the common

Case Case

bile

duct

thiasis,

jaundiced

3#{189} years and

had

Evaluation

portion tamed. intra-

and

Columbia

© American

Roentgen

August 332-0233 Ray

1979 $00.00 Society

tortuous

due

to a distal

docuby a

obstruction.

the

of pruritus

and

present

to have

common

admission

bile

showed

and

biliary

was (fig.

not

tree

given

1 C) revealed

with

orally

duct

that

most

impression

on

very

distal

common

cholangiography,

impression

After

similar

and choledocholithe

medial

of pancreatic mass was enter1 B) showed a massively dilated

of the

transhepatic of the

pain.

exploration.

a marked

obstruction

during

epigastric

cholecystolithiasis

on the

bile

duct.

superimposing

duodenum

was

due

to

common bile duct. A persistent defect in the duodenum at the site of ductal (fig. 1 C) raised the possibility of a small mass, and a 2 cm ampullary carcinoma

was discovered

at surgery.

Univer-

sity, College of Physicians and Surgeons, and Columbia-Presbyterian Medical Center, 622 W. 168th St., New York, NY 10032. AJR 133:233-237, 0361 -8o3x/79/1

complained

he was found

a cholecystectomy

extrahepatic

studies

two

insertion re-

man

before,

during

barium

the dilated after

often

described immediate

duct. [3, 4] Not so well of the second duodenum

of the second duodenum (fig. 1 A), and diagnosis A skinny needle transhepatic cholangiogram (fig.

Although

accepted

and

been and

1

A 73-year-old

Received August 17, 1978; vision April 11, 1979. Department of Radiology,

is dilated

common bile medial aspect

has bulb

Reports

complaints

the

that

by choledochal cysts across the duodenal

Case

2

A 74-year-old

weight

woman

had

abdominal

pain,

nausea

and

vomiting,

jaundice,

and

a 1 3.5

kg

loss over 2 months. Laboratory examination disclosed a total serum bilirubin of 20 mg/i 00 ml and an alkaline phosphatase of 975 IU. Upper gastrointestinal series (fig. 2A) demonstrated a 4 cm smooth impression on the medial aspect of the second duodenum,

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234

GOLD

A

B

Fig. 1 .-Case 1. Smooth mass denal sweep (arrows). B, Transhepatic hugely dilated and slightly tortuous. denum. Separate

and

intraa slightly

entered

the

cholelithiasis

noma duct.

growing

and

c,

cholangiography

extrahepatic

biliary

and

contour of the

circumferentially

x

tree,

to the

ampulla.

a 7 mm

1979

along medial aspect of duocholangiography. Common bile duct Indentation on second part of duo-

transhepatic irregular region

August

impression

of common duct superimposed mass (arrows) was 2 cm ampullary

subsequent

dilated and

Tracing small

AJR:133,

distal

Surgery

1 cm well

around

on

barium-filled carcinoma.

(fig. stones

2B)

showed

a

Case

3

in the gallbladder,

common and

duodenum.

bile

pathology

differentiated the very distal

duct

as it

revealed

biliary common

carcibile

A 38-year-old suffered

white

from

woman

intermittent

serum

bilirubin

was

series

demonstrated

aspect

of the

descending

7.8 a

with

cutaneous

pruritus

and

mg/100

ml

smooth,

duodenum

5

cm

and

neurofibromatosis

jaundice and

upper

impression

a second

for

3 years.

Total

gastrointestinal on

smaller

the

medial

mass

in

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AJR:133,

August

DUODENUM

1979

COMPRESSED

BY

A

DILATED

COMMON

DUCT

235

B

Fig. 2.-Case impressing medial

2. A, Smooth, double impression (arrows) on descending duodenum. Slight contour irregularity of distal duct caused

the third portion of the duodenum a submucosal mass in the third

papilla

of Vater, making

(fig. 3A). Duodenoscopy portion at the location

retrograde

cannulation

impossible.

showed of a low

Trans-

hepatic cholangiography (fig. 3B) revealed a markedly dilated intraand extrahepatic biliary tree with the common bile duct measuring almost 3.5 cm and tapering to enter the duodenum via a very low lying ampulla. Although the submucosal mass was not readily appreciated on the barium studies, the endoscopic preoperative impression was a strategically placed neurofibroma. However, sur-

gery and pathology ampulla

disclosed

was a nonfunctioning,

that the 2 cm mass distorting ectopic,

the

duodenum. B, Transhepatic by cholangiocarcinoma.

[1 1 ] mentioned

rucci common

bile

apical sharply

monograph,

‘

‘

‘

by

a tubular

post-bulbar

It has

common

duct

the duodenum at duodenum where

‘typical

‘

finding

[of

indentation

a dilated

defect

bulb. The defect in appearance’

Berk

[1 2]

commenting

that

impression

on the

‘

again

‘the

on the is rather [1 1 ]. In a

‘

reiterates

distended

duodenum,

this

duct usually

proin the

segment.”

periodically

also

been

compress

specifically, Hodes et

al.

Whether

hinted

portions

that

of

the dilated

the

second

this

is due

that assumes

‘ ‘

sometimes plus

“sweep.” pancreatic

the medial

a double

to invasion

bile duct

duodenum-

the medial aspect of the duodenal [4] discussing the radiology of

carcinoma, speculated of the duodenal loop

some

the

is an extrinsic

of the duodenal and fairly tubular

recent

may

that

duct]

portion defined

duces

The close proximity of the common bile duct, gallbladder, duodenal bulb, and descending duodenum serves to explain how enlargement of the extrahepatic biliary tree will compress parts of the barium filled duodenum. This phenomenon has been noted for some time. In 1 946, Brown and Harper [5] first suggested that ‘the dilated ducts exert pressure upon the duodenum, often resulting in dilatation of the duodenum bulb and at times causing partial obstruction.” They suggested that the right lateral decubitus position would show this pressure defect on the superior flexure of the duodenum. In 1 954, Hodes et al. [4] noted that ‘the [common bile duct] defect, as a rule lies in the immediate post-bulbar region, behind which most common ducts lie.” Subsequent authors have continued to refer to the bulb being deformed from a dilated common bile duct [5-7], as a ‘post-bulbar impression caused by a widened common bile duct” [3], impression on the “proximal” duodenum

dilated

the dilated bile duct passes behind it, ‘ ‘usually at the junction of the first and second parts’ ‘ [1 0]. While discussing the radiology of jaundice in their monograph, Eaton and Fer-

relationship Discussion

Tortuous,

[8], the dilated common duct deforming ‘ ‘ high noon’ ‘ [9], and impression on the

more

islet cell adenoma.

cholangiography.

contour

aspect

or profile.

pressure

by tumor

or

other

cause, the medial border of the loop seems reduplicated. Seven years later, Salik [3] stated that the widened common bile duct may produce a flattening of the ‘ ‘

inner

part

drawing

of

larged

common

the descending or an 1 976, bile

the

duodenum.

illustrating

the duct,

but

duodenum

associated pancreatic Whalen [8] mentioned

duct

.

.

.

indents

He

postbulbar whether was

produced

impression his ‘double ‘

due

a small

of the contour’

to the common

carcinoma was not that ‘ ‘dilatation of the

the duodenal

bulb,

bile

line

‘

enon

duct

clear. In common

or occasionally,

the

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236

GOLD

A

AJR:133,

proximal Bream

descending duodenum, [1 3] have produced an

‘ ‘ but example

only of

Jacques and this duodenal

mass effect from a dilated common duct. While the anatomic relation of the dilated

common

duct

alluded

to the

others,

descending

our

three

duodenum

cases

are

too

large

to

resection”

[10],

enlarged

common

being

offer

a benign

as well

casement

of the

sweep,

with

can

the

tethering,

or

Intraluminal particularly

masses in those

may cases

reverse

or

[1 4,

pathology

common

in those

of the

advent

be due

to a

cholangiand ultra-

routine upper gastrointestinal series of liver metastases was not helpful.

no evidence

for

first,

workup

of

those

for

patients

either the

jaundice,

sweep

do

defined

smooth

should

suggest

who

poorly

medial

be evaluated

the diagnosis

come

for

symptoms

barium or for

indentation

cautiously

of a dilated

a

on the and

common

should

bile

duct.

REFERENCES 1

2.

ampullary

can

duct. needle transhepatic of the abdomen,

tomography

patients,

with

studies

at least

or

impressions

bile of skinny

computed

of jaundiced

duodenal

mucosa.

or both

(straight arrows). Second Enormous common bile

sonography, it is doubtful that either of these mass impressions on the duodenum in a jaundiced patient would be misdiagnosed for long. In fact, in our own prospective series

no en-

a small

the

ography,

be

of Frostberg,

tumor

either

tortuous

As might

duodenal

1 5],

a benign

However,

smooth with ulceration,

signs the

high.

Nevertheless,

to an

be present around the ampulla, with papillary edema due to an

or pancreatitis carcinoma,

surgical

underlying

‘

of

Al-

part of of the growths

be due

lesion.

3’

fixation

to by

point.

successful

are extremely rigidity, mucosal

‘ ‘

angulation,

stone

of

as a malignant

the impressions of duodenal wall

pancreatic

hope compression

duct

expected evidence

impacted

.

same

bile

been a specific

bile

impression on medial duodenum B, Transhepatic cholangiography.

large,

With

narrowing of the second suggestive of a carcinoma and usually only when

much

this

has

reemphasize

though ‘ ‘ compression with the duodenal loop is highly head of the pancreas . .

.

Han

SY,

five

cases.

Collins

Liebner pre

ampullary

EJ:

and

LC,

Clin

Wright

Radio!

Roentgen

post

op

RM:

Choledochal

20 : 332-336, study

of congenital

analysis

of

cyst:

report

of

1969

five

choledochal

AJR

cases.

cysts-

80:950-960,

1958

region.

Differential sions of the

diagnosis for postbulbar and common duct includes duodenal

cystogastrocolic denum, of the second the

1979

B

Fig. 3.-Case 3. A, Frame from 35 mm upper gastrointestinal examination. Smooth ‘mass” impression in third part of duodenum (curved arrows) at site of low ampulla and islet cell adenoma. duct markedly convex toward descending duodenum.

or

August

ligament,

a dilated liver, and finding

chances

of

portal vein or hepatic a mass in the porta

of a of

angulation

‘

‘double

a pancreatic

density’ or

bulbar impresperistalsis, the

‘

a

artery, hepatis in the

normal

peripancreatic

4.

are

JO:

Hodes and

Pancreatic

AJR PJ,

5.

Brown biliary

6.

McGlone

cancer

and

86:1-28,

1961

Pendergrass

EP,

vaterian

diology

sweep, mass

Salik ognition.

duo-

quadrate lobe [1 1 ]. With a

duodenal

3.

neoplasms:

their

its early

Winston

roentgenologic

NJ:

roentgen

Pancreatic,

recductal

manifestations.

62 : 1 -1 5, 1954 5,

Harper

disease.

FB,

FG: Radiology

Robertson

A new

roentgen

sign

47 : 239-248, DS,

Grogan

in

extrahepatic

1946 JM:

The

roentgenologic

Ra-

AJR:133,

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7.

August 1979

DUODENUM

COMPRESSED

manifestations of pancreatic tumors. Gastroenterology 551-565, 1956 Eyler WA, Clark MD, Rian AL: An evaluation of roentgen

BY

31:

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DILATED

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14. 15.

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choledocholithiasis ogy 102:267-273,

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in obstructive AF: Diagnosis

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of