Association of extrahepatic bile duct duplication with pancreaticobiliary maljunction and congenital biliary dilatation in children: a case report and literature review

Ultrasound of Bile Ducts-An Update on Measurements, Reference Values, and Their Influencing Factors

Objective: To provide an overview of the technique and normal values of ultrasound studies of the bile system based on the published literature. Methods: A literature search for ultrasound studies with measurements of the bile ducts in healthy subjects was performed. Relevant data published between 1975 and end of 2024 were extracted, discussed, and complemented with the own experiences of the authors. The clinical implications are presented and discussed. Results: For the diameter of the common bile duct, reference values between 5 and 9 mm have been published. The main influencing factors are age and history of cholecystectomy, and other factors to be considered are discussed here. The cut-off for the common bile duct wall is set at 1.5 mm. The literature on measurements of intrahepatic bile ducts is scarce. A diameter of <2-3 mm can be considered normal. The method of ultrasound examination is presented here, as well as a comparison with other imaging methods and their clinical implications. Conclusions: Standardized measurement techniques and normal values in the context of influencing factors are crucial for the ultrasound examination of the bile system.

An extremely rare combination of choledochocele and bile duct duplication escalating severe acute pancreatitis and cholangitis: A case report

BACKGROUND

Combination of choledochocele and extra-hepatic duct duplication is an extremely rare congenital abnormality.

CASE PRESENTATION

The patient was an 81-year-old Japanese man. He visited the emergency room for severe abdominal colic pain. He was diagnosed with severe pancreatitis with cholelithiasis and treated conservatively by percutaneous trans-hepatic gallbladder drainage (PTGBD) for 4 months. Thereafter, he was transferred to our institute and cholangiography was performed via the PTGBD tube, revealing cholecysto- and choledocho-lithiasis. The cystic-duct joined the right hepatic duct with extra-hepatic bile duct duplication and the terminal bile duct flowed into the cystic papilla of Vater. The main pancreatic duct also joined into the cystic papilla. These observations confirmed choledochocele with extra-hepatic bile duct duplication. Surgical exploration was performed, and hepatico-jejunostomy with hepatic-ductplasty and cholecystectomy with choledocholithotomy were carried out. He was discharged and his course was uneventful.

CONCLUSION

A very rare combined case of choledochocele with bile duct duplication, which would escalate the pancreatitis and cholangitis, was successfully treated. Their pathogeneses in relation to pancreaticobiliary maljunction is discussed.

A new variant of double common bile duct associated with choledochal cyst

Extrahepatic bile duct duplication is a rare biliary anomaly often associated with conditions like cholecysto-choledocholithiasis, choledochal cyst and malignancy. Precise preoperative diagnosis using conventional radiologic imaging still remains a challenge and use of existing classification system is equally confusing. A female patient diagnosed with choledochal cyst by magnetic resonance cholangiopancreatography was found to have an associated new variant of double common bile duct during surgery. The variant discovered could not be classified by existing classification systems and was missed by preoperative imaging. Recognition of existence of this anomaly that warrants careful dissection during biliary surgery is necessary to avoid inadvertent biliary injury as preoperative diagnosis still remains a challenge. Review of existing classification systems is required to include newly discovered variants.

Asymptomatic Bile Duct Dilatation in Children: Is It a Disease?

PURPOSE

Bile duct dilatation is a relatively common sonographic finding; nevertheless, its clinical significance in children is controversial because little research has been done in the area. Therefore, we investigated the natural course and clinical significance of biliary duct dilatation in children.

METHODS

We performed a retrospective study of 181 children (range, 1-day-old to 17-year-old) in whom dilatation of the intrahepatic duct and/or common hepatic duct and/or common bile duct was detected by abdominal ultrasonography at the Severance Children's Hospital between November 2005 and March 2014. We reviewed and analyzed laboratory test results, clinical manifestations, and clinical course in these patients.

RESULTS

Pediatric patients (n=181) were enrolled in the study and divided into two groups. The first group included 59 subjects, without definitive cause of bile duct dilatation, who did not require treatment; the second group included 122 subjects, with definitive cause of bile duct dilatation or underlying biliary disease, who did require treatment. In the first group, 24 patients (40.7%) showed spontaneous resolution of bile duct dilatation, 20 patients (33.9%) showed no change, and 15 patients (25.4%) were lost to follow-up. In the second group, 31 patients were diagnosed with choledochal cysts, and 91 patients presented with biliary tract dilatations due to secondary causes, such as gallbladder or liver disease, post-operative complications, or malignancy.

CONCLUSION

Biliary dilatation in pediatric patients without symptoms, and without laboratory and other sonographic abnormalities, showed a benign clinical course. No pathologic conditions were noted on follow-up ultrasonography.

Liver, biliary and pancreatic injuries in pancreaticobiliary maljunction model in cats

BACKGROUND

Pancreaticobiliary maljunction is a high risk factor of pancreatitis and biliary tract cancer. How this maljunction affects the liver remains obscure. This study aimed to examine the effects of pancreaticobiliary maljunction on the liver, pancreas and gallbladder in a cat model.

METHODS

A model of choledocho-pancreatic side-to-side ductal anastomosis was created in ten cats. Before the procedure, a small piece of tissue from the liver, pancreas and gallbladder was collected as a control. The common channel formation was checked by cholecystography. The livers, pancreases and gallbladders of these cats were harvested for histological examination. The expression of proliferating cell nuclear antigen in the gallbladder was examined with immunohistochemistry.

RESULTS

Seven of the 10 cats survived for 6 months after surgery. The color of the liver was darker in the PBM model than the control specimen, with nodules on the surface. Histological examination showed ballooning changes and inflammatory infiltrations and the histopathological score increased significantly (P<0.05). Also, mitochondria swelling and lipid droplet in cytoplasm were observed under an electron microscope. The pancreas also appeared darker in the PBM model than the control specimen and dilated pancreatic ducts were found in three cats. Histopathological examination revealed vascular proliferation and inflammatory infiltration with numerous neutrophils. Gallbladder epithelial cells were featured by expanded endoplasmic reticulum, increased intercellular space and cellular nucleus deformation. The positive cells of proliferating cell nuclear antigen were increased significantly (P<0.05).

CONCLUSION

The present study demonstrated that pancreaticobiliary maljunction can lead to the injuries of the liver, pancreas and gallbladder.

Common bile duct duplication: the more the murkier

Congenital duplication of the common bile duct is an extremely rare anomaly of the biliary tract, which putatively represents failure of regression of the embryological double biliary system. Depending on the morphology of the duplicated bile duct, the anomaly can be classified into five distinct subtypes as per the modified classification (proposed by Choi et al). Among the five subtypes of bile duct duplication, type V duplication is considered to be the least common with only two previous cases of type Va variant reported in medical literature prior to the current report.

Double common bile duct with choledochal cyst and cholelithiasis: report of a case

Double common bile duct (DCBD) is a rare congenital anomaly of the biliary system, often associated with biliary lithiasis, choledochal cyst, pancreaticobiliary maljunction (PBM), and upper gastrointestinal tract malignancies. We report a case of type I DCBD with choledochal cyst and cholelithiasis in a 52-year-old Chinese man. We also reviewed 24 cases of DCBD reported in the Chinese literature between 1965 and 2012. Most (58.3%) of these cases were classified as type I DCBD, with accompanying choledocholithiasis in 79.2%, cholecystolithiasis in 37.5%, choledochal cyst in 33.3%, and PBM in 8.3%. There was no case of concomitant cancer. The type and coexistence of PBM with DCBD are clinically important because of its close implications with concomitant pathology. Most Chinese people with DCBD have type I. Moreover, the high incidences of choledochal cyst and biliary lithiasis and the extremely low incidences of PBM and biliary cancer are the major clinical characteristics of DCBD in China.