Ectopic opening of the common bile duct in the duodenal bulb: clinical implications

BACKGROUND: An ectopic opening of the common bile duct in the duodenal bulb is extremely rare, and the clinical significance of this anomaly has not been clarified. This study analyzed the clinical implications and cholangiographic findings of this anomaly. METHODS: A total of 18 patients (15 men, 3 women; median age, 51 years) with an ectopic opening of the common bile duct in the duodenal bulb were studied. Medical records, endoscopic findings, and cholangiographic and other radiographic findings were reviewed. RESULTS: All 18 patients had biliary pain; 7 had fever and chills. Fifteen (83%) had diffuse dilatation of the extrahepatic bile ducts with or without intrahepatic bile duct dilation. Associated bile duct stones were found in 10 (56%) patients. The papilla in the bulb had an orifice stained with bile at endoscopy, which was associated with duodenal ulcer disease found in 13 (72%) patients. The distal end of the common bile duct was tapered and narrowed and had a hook shape in all patients. CONCLUSION: An ectopic opening of the common bile duct in the duodenal bulb may be associated with clinical entities such as recurrent or intractable duodenal ulcer, choledocholithiasis, or acute cholangitis. Although these openings are rare, knowledge of the endoscopic and radiographic findings of an ectopic opening of the common bile duct in the duodenal bulb may help to clarify the cause of chronic recurrent duodenal ulcer disease in some patients and prevent damage to the bile duct during surgery.     

Anomalous opening of the common bile duct into the duodenal bulb: endoscopic treatment

Background  

Anomalous biliary opening especially the presence of the ampulla of Vater in the duodenal bulb is a very rare phenomenon. We report clinical implications, laboratory and ERCP findings and also therapeutic approaches in 53 cases.     

Distal common bile duct stenosis secondary to benign duodenal ulceration: report of a case

Obstructive jaundice is a very rare complication of peptic ulcer disease. We report a patient who presented with symptoms suggestive of malignant distal common bile duct stenosis. A final diagnosis of benign duodenal ulcer with stricture of the common bile duct was made. A short review of the literature is also presented.     

EUS diagnosis of ectopic opening of the common bile duct in the duodenal bulb： A case report

Among the various congenital anomalies of the biliary system, an ectopic opening of the common bile duct (CBD) in the duodenal bulb is extremely rare. ERCP is essential for diagnosing the anomaly. A 55-year-old male was admitted to hospital for severe right upper quadrant abdominal pain, followed by fever, chills, elevated body temperature and mild icterus. The diagnosis of ectopic opening of CBD in the duodenal bulb was established on endoscopic ultraso-nography (EUS), which clearly demonstrated dilated CBD, with multiple stones and air in the lumen, draining into the bulb. A normal pancreatic duct, which did not drain into the bulb, was also observed. This finding was confirmed on ERCP and surgery. As far as we know, this is the first case of this anomaly diagnosed by EUS. Ectopic opening of the CBD in the duodenal bulb is not an incidental finding, but a pathologic condition which can be associated with clinical entities such as recurrent or intractable duodenal ulcer, recurrent biliary pain, choledocholithiasis or acute cholangitis. Endoscopic ultrasonography features allow preoperative diagnosis of this anomaly and can replace ERCP as a first diagnostic tool in such clinical circumstances. Embryology of the anomalies of the extrahepatic biliary tree has been also reviewed.     

A common bile duct web in association with common bile duct stone]

Webs are diagnosed by their characteristic appearance on imaging studies, typically appearing as thin, radiolucent rings with or without dilatation of the organ proximal to it. Like in other organs, the etiology of webs in the common bile duct is controversial. Some webs are thought to be congenital, whereas others occur in the presence of chronic inflammation, suggesting a pathogenic relationship. We report a case of a common bile duct septum in association with numerous large black pigment stones in a 62-year-old woman. The patient was treated by cholecystectomy with T-tube insertion.     

Juxtapapillary duodenal diverticula predispose to common bile duct stones

In an endoscopic study of 107 patients with suspected common bile duct calculi, 26 were found at retrograde cholangiography to have juxtapapillary diverticula (JPD). Over 80% of these patients had common bile duct calculi, compared with only 52% among those without any JPD (p less than 0.01).     

Adenomyoma of the distal common bile duct. An uncommon cause of stenosis of the extrahepatic bile duct

We report the case of a 68-year-old man with adenomyoma of the distal common bile duct, fortuitously discovered on a surgical specimen of a Whipple procedure. To our knowledge, three similar cases have been reported; all patients were operated on with the diagnosis of malignancy: adenomyoma was always discovered on the surgical specimen. Adenomyomas are rare tumors and their origin is discussed. Adenomyoma of the distal common hile duct should be considered as enteropancreatic heterotopia.     

Pathology of common bile duct stenosis in cystic fibrosis.

A case of cystic fibrosis complicated by common bile duct stenosis is described. Surgery successfully relieved the obstruction, but was complicated by Candida septicaemia. The previously unreported histological abnormalities of the common bile duct are discussed.     

Congenital web of the common bile duct in association with cholelithiasis

Congenital web formations are extremely rare anomalies of the extrahepatic biliary tree. The age at presentation and the clinical symptomatology of these anomalies depend on the grade of the biliary obstruction. We report a case of a common bile duct septum in association with cholelithiasis in a 30‐year‐old woman. The diagnosis was made on preoperative magnetic resonance cholangiopancreatography (MRCP) and confirmed with intraoperative cholangiography. Because all known causes of acquired web formation were excluded, a congenital origin of the web was assumed. The patient was treated with a hepaticoduodenostomy above the level of the septum. The embryological aspects of this rare anomaly are described.     

The variable appearance of distal common bile duct stenosis in chronic pancreatitis

Cholangiograms of 15 patients with stenosis of distal portion of common bile duct due to chronic alcoholic pancreatitis were critically evaluated for stricture shape, length, and maximal diameter of the common bile duct. In these cholangiograms, different shapes of strictured segments were present, including the smooth tapering variety in eight, "funnel shape" in three, and "rat tail," "bent knee," "hourglass," and complete obstruction in one case each. The length of strictured segment ranged from 16 to 57 mm with a mean (+/- S.E.) of 40.7 +/- 4.1 mm. The mean (+/- S.E.) maximal diameter of the dilated portion of common bile duct was 18.9 +/- 1.3 mm with a range of 13-28 mm. There is a wide variety in the shape and length of the stenotic segments of the distal common bile duct in chronic alcoholic pancreatitis. Moreover, a particular radiologic configuration of common bile duct stricture is not helpful in predicting the nature of the underlying process in this group of patients.     

Prevalence and natural history of distal common bile duct stenosis in alcoholic pancreatitis

Digestive Diseases and Sciences - Distal common bile duct stenosis was observed in 16 (9%) of 170 alcoholic patients admitted to a Veterans Administration Medical Center in the last five years. The...     

Primary closure of the common bile duct in open laparotomy for common bile duct stones

It is common these days to treat common bile duct (CBD) stones using endoscopic techniques. However, severe complications sometimes lead to death despite the great benefit of these techniques. If the patient has many and/or large stones, it can take considerable time for duct clearance, and this is associated with high costs. Therefore, we do not hesitate to choose surgical procedures when necessary. In this study, our aim was to evaluate the usefulness of primary closure of the CBD in open laparotomy for CBD stones. Thirty-four patients with CBD stones were operated on by open laparotomy; primary closure was done in 17 patients (group PC), and T-tube insertion was done in 17 (group TT). We compared the patients' medical records, clinical features, laboratory data, complications, and postoperative hospital admission days. There were no significant intergroup differences in patients' medical records, clinical features, or laboratory data, except for the number of CBD stones. There were no differences in complications. All complications were minor and needed no extra care. The number of postoperative hospital admission days showed a significant difference: 18.3 days in group PC and 31.5 in group TT. There are so many methods to treat CBD stones now that the selection of the procedure can be important for the patient's benefit. We prefer primary closure, to get better quality of life postoperatively and to avoid further operations and any severe complications.