Figure 6c. Papillary adenocarcinoma of the CBD in a 53-year-old man who presented with a 5-month history of intermittent epigastric pain. The patient’s serum bilirubin level was elevated (2.5 mg/dL [42.75 mmol/L]). (a) US image of the extrahepatic duct shows a large, intraluminal soft-tissue mass with a papillary surface (arrows). GB = gallbladder. (b) Contrast-enhanced equilibrium phase CT scan shows a dilated CBD with an intraluminal soft-tissue mass (arrow). (c, d) Sequential ERCP images show small, round or ovoid filling defects of variable size in the CBD. The filling defects changed shape on subsequent images. At the time of ERCP, the endoscopist did not attempt to remove the filling defects. (e) Contrast-enhanced CT scan obtained immediately after ERCP shows the dilated CBD, which contains numerous filling defects floating in contrast material. The soft-tissue mass that was seen in the middle of the CBD in b has moved to the proximal portion of the CBD and floats in the nondependent part of the dilated CHD (arrow). Surgery revealed floating debris and several sessile or nodular superficial masses measuring 0.5-1.0 cm in diameter, but these masses were much smaller and less numerous than those seen at ERCP and CT. (f) Photograph of the inner surface of the CBD shows several small, sessile or polypoid papillary tumors less than 5 mm in diameter (straight arrows). Curved arrow indicates a tissue defect caused by frozen biopsy, arrowheads indicate tiny discrete tumors. p = duodenal papillae. (g) Photomicrograph (original magnification, x40; H-E stain) of the bile duct shows papillary carcinoma that consists of a fibrovascular core covered with columnar epithelial cells (arrowheads). Note the fragmented tumor debris. (Fig 6g reprinted, with permission, from reference 15.)