HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text Full Text (PDF) CME Test (opens in a new window) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Lim, J. H. Articles by Lim, H. K. Search for Related Content PubMed PubMed Citation Articles by Lim, J. H. Articles by Lim, H. K. Related Collections Gastrointestinal Radiology

Papillary Neoplasms of the Bile Duct That Mimic Biliary Stone Disease¹

¹ From the Departments of Radiology (J.H.L., J.W.L., H.K.L.) and Gastroenterology (K.T.L., J.K.L.), Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Ilwon-dong, Kangnam-ku, Seoul, Korea 135-710; and the Departments of Internal Medicine (M.H.K., S.S.L.) and Radiology (T.K.K., M.G.L.), Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea. Presented as an education exhibit at the 2001 RSNA scientific assembly. Received February 19, 2002; revision requested April 23; final revision received July 12; accepted July 15. Address correspondence to J.H.L. (e-mail: jhlim@smc.samsung.co.kr).

View larger version (187K): [in a new window]   Figure 1.  Intrahepatic intraductal papillary adenocarcinoma. Photomicrograph (original magnification, x40; hematoxylin-eosin [H-E] stain) shows myriad frondlike papillary infoldings that consist of slender fibrovascular stalks (open arrow) covered with columnar epithelial cells. The word papillary refers to these projections. Solid arrows indicate the wall of the intrahepatic bile duct.

View larger version (152K): [in a new window]   Figure 2.  Papillary adenoma in a 60-year-old man with recurrent abdominal pain. Endoscopic image of the duodenum obtained after the extraction of "lumps" in the common bile duct (CBD) shows innumerable fragments of tumor debris (arrows) at the orifice of the papilla of Vater. d = duodenal lumen, e = endoscopic tube. The histologic diagnosis was papillary adenoma.

View larger version (171K): [in a new window]   Figure 3a.  Papillary adenomatosis in the intrahepatic ducts in a 60-year-old man with a 1-week history of pain in the right upper abdomen. (a) US image shows dilatation of the left intrahepatic bile duct and a nonshadowing intraductal echogenic focus (arrow). (b, c) Sequential percutaneous transhepatic cholangiograms obtained after forceful injection of contrast material show biliary dilatation and innumerable small, round or oval filling defects that mimic stones in the intrahepatic ducts (arrowheads in b). Note the small, movable filling defects in the second portion of the duodenum (arrows in c); these filling defects represent tumor fragments that became detached and drained into the duodenum. (d) Cholangioscopic image shows innumerable small (1-mm), round, pink-white intraluminal masses that represent papillary tumors. At surgery, there were innumerable small papillary masses in the left and right intrahepatic ducts and CBD. Pathologic examination revealed papillary adenomas with high-grade dysplasia.

View larger version (164K): [in a new window]   Figure 3b.  Papillary adenomatosis in the intrahepatic ducts in a 60-year-old man with a 1-week history of pain in the right upper abdomen. (a) US image shows dilatation of the left intrahepatic bile duct and a nonshadowing intraductal echogenic focus (arrow). (b, c) Sequential percutaneous transhepatic cholangiograms obtained after forceful injection of contrast material show biliary dilatation and innumerable small, round or oval filling defects that mimic stones in the intrahepatic ducts (arrowheads in b). Note the small, movable filling defects in the second portion of the duodenum (arrows in c); these filling defects represent tumor fragments that became detached and drained into the duodenum. (d) Cholangioscopic image shows innumerable small (1-mm), round, pink-white intraluminal masses that represent papillary tumors. At surgery, there were innumerable small papillary masses in the left and right intrahepatic ducts and CBD. Pathologic examination revealed papillary adenomas with high-grade dysplasia.

View larger version (167K): [in a new window]   Figure 3c.  Papillary adenomatosis in the intrahepatic ducts in a 60-year-old man with a 1-week history of pain in the right upper abdomen. (a) US image shows dilatation of the left intrahepatic bile duct and a nonshadowing intraductal echogenic focus (arrow). (b, c) Sequential percutaneous transhepatic cholangiograms obtained after forceful injection of contrast material show biliary dilatation and innumerable small, round or oval filling defects that mimic stones in the intrahepatic ducts (arrowheads in b). Note the small, movable filling defects in the second portion of the duodenum (arrows in c); these filling defects represent tumor fragments that became detached and drained into the duodenum. (d) Cholangioscopic image shows innumerable small (1-mm), round, pink-white intraluminal masses that represent papillary tumors. At surgery, there were innumerable small papillary masses in the left and right intrahepatic ducts and CBD. Pathologic examination revealed papillary adenomas with high-grade dysplasia.

View larger version (117K): [in a new window]   Figure 3d.  Papillary adenomatosis in the intrahepatic ducts in a 60-year-old man with a 1-week history of pain in the right upper abdomen. (a) US image shows dilatation of the left intrahepatic bile duct and a nonshadowing intraductal echogenic focus (arrow). (b, c) Sequential percutaneous transhepatic cholangiograms obtained after forceful injection of contrast material show biliary dilatation and innumerable small, round or oval filling defects that mimic stones in the intrahepatic ducts (arrowheads in b). Note the small, movable filling defects in the second portion of the duodenum (arrows in c); these filling defects represent tumor fragments that became detached and drained into the duodenum. (d) Cholangioscopic image shows innumerable small (1-mm), round, pink-white intraluminal masses that represent papillary tumors. At surgery, there were innumerable small papillary masses in the left and right intrahepatic ducts and CBD. Pathologic examination revealed papillary adenomas with high-grade dysplasia.

View larger version (103K): [in a new window]   Figure 4a.  Papillary adenoma of the CBD in a 67-year-old woman with a 1-month history of intermittent severe pain in the epigastrium and right upper abdomen. (a) US image of the extrahepatic ducts shows an intraluminal echogenic cast. Note the integrity of the echogenic wall of the CHD (arrows). (b) Contrast-enhanced CT scan shows eccentric thickening of the CBD wall (arrow). (c) ERCP image shows nodular and papillary filling defects along the extrahepatic ducts (curved arrow). Note the serrated margin of the CBD (straight arrows), a finding that indicates papillary tumors rather than stones. (d) Endoscopic extraction of the possible stones with a basket maneuver was attempted. This ERCP image was obtained after innumerable tumor fragments and debris had been extracted at the orifice of the papilla of Vater. The histopathologic diagnosis was papillary adenoma.

View larger version (116K): [in a new window]   Figure 4b.  Papillary adenoma of the CBD in a 67-year-old woman with a 1-month history of intermittent severe pain in the epigastrium and right upper abdomen. (a) US image of the extrahepatic ducts shows an intraluminal echogenic cast. Note the integrity of the echogenic wall of the CHD (arrows). (b) Contrast-enhanced CT scan shows eccentric thickening of the CBD wall (arrow). (c) ERCP image shows nodular and papillary filling defects along the extrahepatic ducts (curved arrow). Note the serrated margin of the CBD (straight arrows), a finding that indicates papillary tumors rather than stones. (d) Endoscopic extraction of the possible stones with a basket maneuver was attempted. This ERCP image was obtained after innumerable tumor fragments and debris had been extracted at the orifice of the papilla of Vater. The histopathologic diagnosis was papillary adenoma.

View larger version (168K): [in a new window]   Figure 4c.  Papillary adenoma of the CBD in a 67-year-old woman with a 1-month history of intermittent severe pain in the epigastrium and right upper abdomen. (a) US image of the extrahepatic ducts shows an intraluminal echogenic cast. Note the integrity of the echogenic wall of the CHD (arrows). (b) Contrast-enhanced CT scan shows eccentric thickening of the CBD wall (arrow). (c) ERCP image shows nodular and papillary filling defects along the extrahepatic ducts (curved arrow). Note the serrated margin of the CBD (straight arrows), a finding that indicates papillary tumors rather than stones. (d) Endoscopic extraction of the possible stones with a basket maneuver was attempted. This ERCP image was obtained after innumerable tumor fragments and debris had been extracted at the orifice of the papilla of Vater. The histopathologic diagnosis was papillary adenoma.

View larger version (151K): [in a new window]   Figure 4d.  Papillary adenoma of the CBD in a 67-year-old woman with a 1-month history of intermittent severe pain in the epigastrium and right upper abdomen. (a) US image of the extrahepatic ducts shows an intraluminal echogenic cast. Note the integrity of the echogenic wall of the CHD (arrows). (b) Contrast-enhanced CT scan shows eccentric thickening of the CBD wall (arrow). (c) ERCP image shows nodular and papillary filling defects along the extrahepatic ducts (curved arrow). Note the serrated margin of the CBD (straight arrows), a finding that indicates papillary tumors rather than stones. (d) Endoscopic extraction of the possible stones with a basket maneuver was attempted. This ERCP image was obtained after innumerable tumor fragments and debris had been extracted at the orifice of the papilla of Vater. The histopathologic diagnosis was papillary adenoma.

View larger version (145K): [in a new window]   Figure 5a.  Papillary adenocarcinoma of the extrahepatic duct in a 73-year-old man with a 2-month history of jaundice. (a) US image shows a slightly dilated CBD that contains an echogenic cast. The wall of the bile duct is well preserved and appears as a thin echogenic line (arrow). GB = gallbladder. (b, c) Unenhanced (b) and contrast material-enhanced (c) CT scans show an intraluminal mass in the CBD (arrow). Attenuation of the mass increased from 24 HU on b to 95 HU on c, indicating that the mass represents a tumor attached to the bile duct wall. (d) ERCP image shows multiple large, oval filling defects in the CBD. The filling defects with smooth surfaces (open arrow) are stones, whereas those with papillary surfaces are tumors. The margin of the common hepatic duct (CHD) (solid arrow) is serrated. The bile ducts are dilated as far as the ampulla of Vater. Note the normal duodenal mucosal surface. (e) ERCP image obtained after an attempt to extract the "lumps" with a basket maneuver shows innumerable filling defects of varying size that represent tumor fragments. A stone (open arrow) remains in the bile duct, and only small tissue debris could be removed. The serrated margin of the CHD (solid black arrow) is unchanged (cf d). Note the small and medium-sized filling defects in the second portion of the duodenum (solid white arrows), which represent tumor fragments. Surgery revealed several pigmented stones as well as many tiny (3-5-mm-diameter) fragments of papillary tumor and debris within the extrahepatic ducts. (f) Photomicrograph (original magnification, x40; H-E stain) of tissue debris obtained from the bile ducts at surgery shows innumerable papillary tumor fragments (arrowheads). (g) Low-power photomicrograph (original magnification, x10; H-E stain) of a cut section of the proximal portion of the CHD shows tiny flat papillary carcinomas lining the mucosal surface (curved arrow). A defect caused by bile duct exploration performed during surgery is also seen (straight arrow). Because the superficial papillary tumors were sloughed or denuded before or during surgery, there are no polypoid masses as were seen at US, CT, and ERCP.

View larger version (147K): [in a new window]   Figure 5b.  Papillary adenocarcinoma of the extrahepatic duct in a 73-year-old man with a 2-month history of jaundice. (a) US image shows a slightly dilated CBD that contains an echogenic cast. The wall of the bile duct is well preserved and appears as a thin echogenic line (arrow). GB = gallbladder. (b, c) Unenhanced (b) and contrast material-enhanced (c) CT scans show an intraluminal mass in the CBD (arrow). Attenuation of the mass increased from 24 HU on b to 95 HU on c, indicating that the mass represents a tumor attached to the bile duct wall. (d) ERCP image shows multiple large, oval filling defects in the CBD. The filling defects with smooth surfaces (open arrow) are stones, whereas those with papillary surfaces are tumors. The margin of the common hepatic duct (CHD) (solid arrow) is serrated. The bile ducts are dilated as far as the ampulla of Vater. Note the normal duodenal mucosal surface. (e) ERCP image obtained after an attempt to extract the "lumps" with a basket maneuver shows innumerable filling defects of varying size that represent tumor fragments. A stone (open arrow) remains in the bile duct, and only small tissue debris could be removed. The serrated margin of the CHD (solid black arrow) is unchanged (cf d). Note the small and medium-sized filling defects in the second portion of the duodenum (solid white arrows), which represent tumor fragments. Surgery revealed several pigmented stones as well as many tiny (3-5-mm-diameter) fragments of papillary tumor and debris within the extrahepatic ducts. (f) Photomicrograph (original magnification, x40; H-E stain) of tissue debris obtained from the bile ducts at surgery shows innumerable papillary tumor fragments (arrowheads). (g) Low-power photomicrograph (original magnification, x10; H-E stain) of a cut section of the proximal portion of the CHD shows tiny flat papillary carcinomas lining the mucosal surface (curved arrow). A defect caused by bile duct exploration performed during surgery is also seen (straight arrow). Because the superficial papillary tumors were sloughed or denuded before or during surgery, there are no polypoid masses as were seen at US, CT, and ERCP.

View larger version (153K): [in a new window]   Figure 5c.  Papillary adenocarcinoma of the extrahepatic duct in a 73-year-old man with a 2-month history of jaundice. (a) US image shows a slightly dilated CBD that contains an echogenic cast. The wall of the bile duct is well preserved and appears as a thin echogenic line (arrow). GB = gallbladder. (b, c) Unenhanced (b) and contrast material-enhanced (c) CT scans show an intraluminal mass in the CBD (arrow). Attenuation of the mass increased from 24 HU on b to 95 HU on c, indicating that the mass represents a tumor attached to the bile duct wall. (d) ERCP image shows multiple large, oval filling defects in the CBD. The filling defects with smooth surfaces (open arrow) are stones, whereas those with papillary surfaces are tumors. The margin of the common hepatic duct (CHD) (solid arrow) is serrated. The bile ducts are dilated as far as the ampulla of Vater. Note the normal duodenal mucosal surface. (e) ERCP image obtained after an attempt to extract the "lumps" with a basket maneuver shows innumerable filling defects of varying size that represent tumor fragments. A stone (open arrow) remains in the bile duct, and only small tissue debris could be removed. The serrated margin of the CHD (solid black arrow) is unchanged (cf d). Note the small and medium-sized filling defects in the second portion of the duodenum (solid white arrows), which represent tumor fragments. Surgery revealed several pigmented stones as well as many tiny (3-5-mm-diameter) fragments of papillary tumor and debris within the extrahepatic ducts. (f) Photomicrograph (original magnification, x40; H-E stain) of tissue debris obtained from the bile ducts at surgery shows innumerable papillary tumor fragments (arrowheads). (g) Low-power photomicrograph (original magnification, x10; H-E stain) of a cut section of the proximal portion of the CHD shows tiny flat papillary carcinomas lining the mucosal surface (curved arrow). A defect caused by bile duct exploration performed during surgery is also seen (straight arrow). Because the superficial papillary tumors were sloughed or denuded before or during surgery, there are no polypoid masses as were seen at US, CT, and ERCP.

View larger version (166K): [in a new window]   Figure 5d.  Papillary adenocarcinoma of the extrahepatic duct in a 73-year-old man with a 2-month history of jaundice. (a) US image shows a slightly dilated CBD that contains an echogenic cast. The wall of the bile duct is well preserved and appears as a thin echogenic line (arrow). GB = gallbladder. (b, c) Unenhanced (b) and contrast material-enhanced (c) CT scans show an intraluminal mass in the CBD (arrow). Attenuation of the mass increased from 24 HU on b to 95 HU on c, indicating that the mass represents a tumor attached to the bile duct wall. (d) ERCP image shows multiple large, oval filling defects in the CBD. The filling defects with smooth surfaces (open arrow) are stones, whereas those with papillary surfaces are tumors. The margin of the common hepatic duct (CHD) (solid arrow) is serrated. The bile ducts are dilated as far as the ampulla of Vater. Note the normal duodenal mucosal surface. (e) ERCP image obtained after an attempt to extract the "lumps" with a basket maneuver shows innumerable filling defects of varying size that represent tumor fragments. A stone (open arrow) remains in the bile duct, and only small tissue debris could be removed. The serrated margin of the CHD (solid black arrow) is unchanged (cf d). Note the small and medium-sized filling defects in the second portion of the duodenum (solid white arrows), which represent tumor fragments. Surgery revealed several pigmented stones as well as many tiny (3-5-mm-diameter) fragments of papillary tumor and debris within the extrahepatic ducts. (f) Photomicrograph (original magnification, x40; H-E stain) of tissue debris obtained from the bile ducts at surgery shows innumerable papillary tumor fragments (arrowheads). (g) Low-power photomicrograph (original magnification, x10; H-E stain) of a cut section of the proximal portion of the CHD shows tiny flat papillary carcinomas lining the mucosal surface (curved arrow). A defect caused by bile duct exploration performed during surgery is also seen (straight arrow). Because the superficial papillary tumors were sloughed or denuded before or during surgery, there are no polypoid masses as were seen at US, CT, and ERCP.

View larger version (167K): [in a new window]   Figure 5e.  Papillary adenocarcinoma of the extrahepatic duct in a 73-year-old man with a 2-month history of jaundice. (a) US image shows a slightly dilated CBD that contains an echogenic cast. The wall of the bile duct is well preserved and appears as a thin echogenic line (arrow). GB = gallbladder. (b, c) Unenhanced (b) and contrast material-enhanced (c) CT scans show an intraluminal mass in the CBD (arrow). Attenuation of the mass increased from 24 HU on b to 95 HU on c, indicating that the mass represents a tumor attached to the bile duct wall. (d) ERCP image shows multiple large, oval filling defects in the CBD. The filling defects with smooth surfaces (open arrow) are stones, whereas those with papillary surfaces are tumors. The margin of the common hepatic duct (CHD) (solid arrow) is serrated. The bile ducts are dilated as far as the ampulla of Vater. Note the normal duodenal mucosal surface. (e) ERCP image obtained after an attempt to extract the "lumps" with a basket maneuver shows innumerable filling defects of varying size that represent tumor fragments. A stone (open arrow) remains in the bile duct, and only small tissue debris could be removed. The serrated margin of the CHD (solid black arrow) is unchanged (cf d). Note the small and medium-sized filling defects in the second portion of the duodenum (solid white arrows), which represent tumor fragments. Surgery revealed several pigmented stones as well as many tiny (3-5-mm-diameter) fragments of papillary tumor and debris within the extrahepatic ducts. (f) Photomicrograph (original magnification, x40; H-E stain) of tissue debris obtained from the bile ducts at surgery shows innumerable papillary tumor fragments (arrowheads). (g) Low-power photomicrograph (original magnification, x10; H-E stain) of a cut section of the proximal portion of the CHD shows tiny flat papillary carcinomas lining the mucosal surface (curved arrow). A defect caused by bile duct exploration performed during surgery is also seen (straight arrow). Because the superficial papillary tumors were sloughed or denuded before or during surgery, there are no polypoid masses as were seen at US, CT, and ERCP.

View larger version (133K): [in a new window]   Figure 5f.  Papillary adenocarcinoma of the extrahepatic duct in a 73-year-old man with a 2-month history of jaundice. (a) US image shows a slightly dilated CBD that contains an echogenic cast. The wall of the bile duct is well preserved and appears as a thin echogenic line (arrow). GB = gallbladder. (b, c) Unenhanced (b) and contrast material-enhanced (c) CT scans show an intraluminal mass in the CBD (arrow). Attenuation of the mass increased from 24 HU on b to 95 HU on c, indicating that the mass represents a tumor attached to the bile duct wall. (d) ERCP image shows multiple large, oval filling defects in the CBD. The filling defects with smooth surfaces (open arrow) are stones, whereas those with papillary surfaces are tumors. The margin of the common hepatic duct (CHD) (solid arrow) is serrated. The bile ducts are dilated as far as the ampulla of Vater. Note the normal duodenal mucosal surface. (e) ERCP image obtained after an attempt to extract the "lumps" with a basket maneuver shows innumerable filling defects of varying size that represent tumor fragments. A stone (open arrow) remains in the bile duct, and only small tissue debris could be removed. The serrated margin of the CHD (solid black arrow) is unchanged (cf d). Note the small and medium-sized filling defects in the second portion of the duodenum (solid white arrows), which represent tumor fragments. Surgery revealed several pigmented stones as well as many tiny (3-5-mm-diameter) fragments of papillary tumor and debris within the extrahepatic ducts. (f) Photomicrograph (original magnification, x40; H-E stain) of tissue debris obtained from the bile ducts at surgery shows innumerable papillary tumor fragments (arrowheads). (g) Low-power photomicrograph (original magnification, x10; H-E stain) of a cut section of the proximal portion of the CHD shows tiny flat papillary carcinomas lining the mucosal surface (curved arrow). A defect caused by bile duct exploration performed during surgery is also seen (straight arrow). Because the superficial papillary tumors were sloughed or denuded before or during surgery, there are no polypoid masses as were seen at US, CT, and ERCP.

View larger version (100K): [in a new window]   Figure 5g.  Papillary adenocarcinoma of the extrahepatic duct in a 73-year-old man with a 2-month history of jaundice. (a) US image shows a slightly dilated CBD that contains an echogenic cast. The wall of the bile duct is well preserved and appears as a thin echogenic line (arrow). GB = gallbladder. (b, c) Unenhanced (b) and contrast material-enhanced (c) CT scans show an intraluminal mass in the CBD (arrow). Attenuation of the mass increased from 24 HU on b to 95 HU on c, indicating that the mass represents a tumor attached to the bile duct wall. (d) ERCP image shows multiple large, oval filling defects in the CBD. The filling defects with smooth surfaces (open arrow) are stones, whereas those with papillary surfaces are tumors. The margin of the common hepatic duct (CHD) (solid arrow) is serrated. The bile ducts are dilated as far as the ampulla of Vater. Note the normal duodenal mucosal surface. (e) ERCP image obtained after an attempt to extract the "lumps" with a basket maneuver shows innumerable filling defects of varying size that represent tumor fragments. A stone (open arrow) remains in the bile duct, and only small tissue debris could be removed. The serrated margin of the CHD (solid black arrow) is unchanged (cf d). Note the small and medium-sized filling defects in the second portion of the duodenum (solid white arrows), which represent tumor fragments. Surgery revealed several pigmented stones as well as many tiny (3-5-mm-diameter) fragments of papillary tumor and debris within the extrahepatic ducts. (f) Photomicrograph (original magnification, x40; H-E stain) of tissue debris obtained from the bile ducts at surgery shows innumerable papillary tumor fragments (arrowheads). (g) Low-power photomicrograph (original magnification, x10; H-E stain) of a cut section of the proximal portion of the CHD shows tiny flat papillary carcinomas lining the mucosal surface (curved arrow). A defect caused by bile duct exploration performed during surgery is also seen (straight arrow). Because the superficial papillary tumors were sloughed or denuded before or during surgery, there are no polypoid masses as were seen at US, CT, and ERCP.

View larger version (130K): [in a new window]   Figure 6a.  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.)

View larger version (122K): [in a new window]   Figure 6b.  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.)

View larger version (129K): [in a new window]   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.)

View larger version (132K): [in a new window]   Figure 6d.  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.)

View larger version (131K): [in a new window]   Figure 6e.  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.)

View larger version (149K): [in a new window]   Figure 6f.  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.)

View larger version (110K): [in a new window]   Figure 6g.  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.)

View larger version (116K): [in a new window]   Figure 7a.  Papillary adenocarcinomatosis in the intrahepatic and extrahepatic bile ducts in a 78-year-old woman with a 3-day history of jaundice. Biopsy revealed atypical cells that were suggestive of adenocarcinoma. (a) Unenhanced CT scan shows dilated intrahepatic and extrahepatic ducts. The bile ducts are slightly hypoattenuating relative to the liver (arrow). (b) Contrast-enhanced CT scan shows a dilated extrahepatic duct that contains ill-defined, slightly hyperattenuating intraluminal lesions (arrow). The wall of the extrahepatic bile duct is thickened and enhanced. (c, d) Sequential ERCP images show innumerable small filling defects that represent papillary tumors in the intrahepatic and extrahepatic bile ducts (arrows). There were no bile duct stones. Note the irregularity along the extrahepatic ducts.

View larger version (127K): [in a new window]   Figure 7b.  Papillary adenocarcinomatosis in the intrahepatic and extrahepatic bile ducts in a 78-year-old woman with a 3-day history of jaundice. Biopsy revealed atypical cells that were suggestive of adenocarcinoma. (a) Unenhanced CT scan shows dilated intrahepatic and extrahepatic ducts. The bile ducts are slightly hypoattenuating relative to the liver (arrow). (b) Contrast-enhanced CT scan shows a dilated extrahepatic duct that contains ill-defined, slightly hyperattenuating intraluminal lesions (arrow). The wall of the extrahepatic bile duct is thickened and enhanced. (c, d) Sequential ERCP images show innumerable small filling defects that represent papillary tumors in the intrahepatic and extrahepatic bile ducts (arrows). There were no bile duct stones. Note the irregularity along the extrahepatic ducts.

View larger version (128K): [in a new window]   Figure 7c.  Papillary adenocarcinomatosis in the intrahepatic and extrahepatic bile ducts in a 78-year-old woman with a 3-day history of jaundice. Biopsy revealed atypical cells that were suggestive of adenocarcinoma. (a) Unenhanced CT scan shows dilated intrahepatic and extrahepatic ducts. The bile ducts are slightly hypoattenuating relative to the liver (arrow). (b) Contrast-enhanced CT scan shows a dilated extrahepatic duct that contains ill-defined, slightly hyperattenuating intraluminal lesions (arrow). The wall of the extrahepatic bile duct is thickened and enhanced. (c, d) Sequential ERCP images show innumerable small filling defects that represent papillary tumors in the intrahepatic and extrahepatic bile ducts (arrows). There were no bile duct stones. Note the irregularity along the extrahepatic ducts.

View larger version (125K): [in a new window]   Figure 7d.  Papillary adenocarcinomatosis in the intrahepatic and extrahepatic bile ducts in a 78-year-old woman with a 3-day history of jaundice. Biopsy revealed atypical cells that were suggestive of adenocarcinoma. (a) Unenhanced CT scan shows dilated intrahepatic and extrahepatic ducts. The bile ducts are slightly hypoattenuating relative to the liver (arrow). (b) Contrast-enhanced CT scan shows a dilated extrahepatic duct that contains ill-defined, slightly hyperattenuating intraluminal lesions (arrow). The wall of the extrahepatic bile duct is thickened and enhanced. (c, d) Sequential ERCP images show innumerable small filling defects that represent papillary tumors in the intrahepatic and extrahepatic bile ducts (arrows). There were no bile duct stones. Note the irregularity along the extrahepatic ducts.

View larger version (144K): [in a new window]   Figure 8.  Recurrent pyogenic cholangitis in a 45-year-old man. ERCP image shows three stones in the intrahepatic and extrahepatic bile ducts that manifest as filling defects with smooth margins (arrows). The filling defect in the extrahepatic duct moved readily.