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Intraductal Papillary Mucinous Tumor of the Bile Ducts¹

¹ From the Departments of Radiology (J.H.L., S.H.K., H.Y.K., H.K.L.) and Pathology (S.Y.S.), Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Ilwon-dong, Kangnam-ku, Seoul 135\N710, Korea; Department of Radiology, Wonkwang University School of Medicine, Chunbuk, Korea (K.H.Y.); and Department of Radiology, Dong-A University Hospital, Busan, Korea (K.J.N.). Presented as an education exhibit at the 2002 RSNA scientific assembly. Received January 3, 2003; revision requested March 10 and received March 28; accepted May 27. Supported in part by Sungkyunkwan University and Wonkwang University. All authors have no financial relationships to disclose. Address correspondence to J.H.L. (e-mail: jhlim@smc.samsung.co.kr).

View larger version (137K): [in a new window]   Figure 1a.  Gross, histopathologic, and endoscopic findings in intraductal papillary mucinous tumor of the bile ducts. (a) Photograph shows characteristic myriad frondlike papillary infoldings. (b) Photomicrograph (original magnification, x100; hematoxylin-eosin stain) shows multiple ductules with tall columnar mucinous epithelial cells and fibrovascular cores (arrows). (c) Endoscopic image of the duodenum shows greenish mucin (arrows) draining from a patulous papillary orifice.

View larger version (174K): [in a new window]   Figure 1b.  Gross, histopathologic, and endoscopic findings in intraductal papillary mucinous tumor of the bile ducts. (a) Photograph shows characteristic myriad frondlike papillary infoldings. (b) Photomicrograph (original magnification, x100; hematoxylin-eosin stain) shows multiple ductules with tall columnar mucinous epithelial cells and fibrovascular cores (arrows). (c) Endoscopic image of the duodenum shows greenish mucin (arrows) draining from a patulous papillary orifice.

View larger version (171K): [in a new window]   Figure 1c.  Gross, histopathologic, and endoscopic findings in intraductal papillary mucinous tumor of the bile ducts. (a) Photograph shows characteristic myriad frondlike papillary infoldings. (b) Photomicrograph (original magnification, x100; hematoxylin-eosin stain) shows multiple ductules with tall columnar mucinous epithelial cells and fibrovascular cores (arrows). (c) Endoscopic image of the duodenum shows greenish mucin (arrows) draining from a patulous papillary orifice.

View larger version (39K): [in a new window]   Figure 2a.  Patterns of biliary dilatation caused by intraductal papillary mucinous tumor of the bile ducts. Schematics show segmental or lobar dilatation produced by tumor-induced stenosis (a), aneurysmal dilatation caused by multiple fungating tumors (b), generalized dilatation without any visible tumor (c), and generalized dilatation with disproportionately greater dilatation of the hepatic segmental bile ducts containing a tumor (d).

View larger version (37K): [in a new window]   Figure 2b.  Patterns of biliary dilatation caused by intraductal papillary mucinous tumor of the bile ducts. Schematics show segmental or lobar dilatation produced by tumor-induced stenosis (a), aneurysmal dilatation caused by multiple fungating tumors (b), generalized dilatation without any visible tumor (c), and generalized dilatation with disproportionately greater dilatation of the hepatic segmental bile ducts containing a tumor (d).

View larger version (39K): [in a new window]   Figure 2c.  Patterns of biliary dilatation caused by intraductal papillary mucinous tumor of the bile ducts. Schematics show segmental or lobar dilatation produced by tumor-induced stenosis (a), aneurysmal dilatation caused by multiple fungating tumors (b), generalized dilatation without any visible tumor (c), and generalized dilatation with disproportionately greater dilatation of the hepatic segmental bile ducts containing a tumor (d).

View larger version (44K): [in a new window]   Figure 2d.  Patterns of biliary dilatation caused by intraductal papillary mucinous tumor of the bile ducts. Schematics show segmental or lobar dilatation produced by tumor-induced stenosis (a), aneurysmal dilatation caused by multiple fungating tumors (b), generalized dilatation without any visible tumor (c), and generalized dilatation with disproportionately greater dilatation of the hepatic segmental bile ducts containing a tumor (d).

View larger version (145K): [in a new window]   Figure 3a.  Papillary adenocarcinoma in a 62-year-old man who presented with epigastric pain of 6 months’ duration. Transverse contrast-enhanced CT image (a) and sonogram (b) show a nodular mass (arrow) and severe dilatation of the lateral segmental bile ducts of the left hepatic lobe. Slight dilatation of the right intrahepatic bile ducts, also visible, is caused by clonorchiasis. (c) ERCP image shows complete obstruction of the lateral segmental bile duct (arrow), normal extrahepatic bile ducts and right hepatic duct, and mild dilatation of the right intrahepatic bile ducts because of clonorchiasis. (d) Photomicrograph (original magnification, x40; hematoxylin-eosin stain) shows a papillary tumor (arrow) obstructing a segmental bile duct. (Reprinted, with permission, from reference 12.)

View larger version (122K): [in a new window]   Figure 3b.  Papillary adenocarcinoma in a 62-year-old man who presented with epigastric pain of 6 months’ duration. Transverse contrast-enhanced CT image (a) and sonogram (b) show a nodular mass (arrow) and severe dilatation of the lateral segmental bile ducts of the left hepatic lobe. Slight dilatation of the right intrahepatic bile ducts, also visible, is caused by clonorchiasis. (c) ERCP image shows complete obstruction of the lateral segmental bile duct (arrow), normal extrahepatic bile ducts and right hepatic duct, and mild dilatation of the right intrahepatic bile ducts because of clonorchiasis. (d) Photomicrograph (original magnification, x40; hematoxylin-eosin stain) shows a papillary tumor (arrow) obstructing a segmental bile duct. (Reprinted, with permission, from reference 12.)

View larger version (146K): [in a new window]   Figure 3c.  Papillary adenocarcinoma in a 62-year-old man who presented with epigastric pain of 6 months’ duration. Transverse contrast-enhanced CT image (a) and sonogram (b) show a nodular mass (arrow) and severe dilatation of the lateral segmental bile ducts of the left hepatic lobe. Slight dilatation of the right intrahepatic bile ducts, also visible, is caused by clonorchiasis. (c) ERCP image shows complete obstruction of the lateral segmental bile duct (arrow), normal extrahepatic bile ducts and right hepatic duct, and mild dilatation of the right intrahepatic bile ducts because of clonorchiasis. (d) Photomicrograph (original magnification, x40; hematoxylin-eosin stain) shows a papillary tumor (arrow) obstructing a segmental bile duct. (Reprinted, with permission, from reference 12.)

View larger version (110K): [in a new window]   Figure 3d.  Papillary adenocarcinoma in a 62-year-old man who presented with epigastric pain of 6 months’ duration. Transverse contrast-enhanced CT image (a) and sonogram (b) show a nodular mass (arrow) and severe dilatation of the lateral segmental bile ducts of the left hepatic lobe. Slight dilatation of the right intrahepatic bile ducts, also visible, is caused by clonorchiasis. (c) ERCP image shows complete obstruction of the lateral segmental bile duct (arrow), normal extrahepatic bile ducts and right hepatic duct, and mild dilatation of the right intrahepatic bile ducts because of clonorchiasis. (d) Photomicrograph (original magnification, x40; hematoxylin-eosin stain) shows a papillary tumor (arrow) obstructing a segmental bile duct. (Reprinted, with permission, from reference 12.)

View larger version (123K): [in a new window]   Figure 4a.  Papillary adenocarcinoma in a 63-year-old man who presented with epigastric pain. (a, b) Transverse contrast-enhanced CT images (a at a level higher than b) show aneurysmal dilatation of the lateral segmental bile ducts of the left hepatic lobe containing multiple fungating masses and associated peripheral bile duct dilatation (arrow in a). (c) Photograph of the resected specimen shows fungating tumors. Histopathologic findings confirmed the diagnosis.

View larger version (122K): [in a new window]   Figure 4b.  Papillary adenocarcinoma in a 63-year-old man who presented with epigastric pain. (a, b) Transverse contrast-enhanced CT images (a at a level higher than b) show aneurysmal dilatation of the lateral segmental bile ducts of the left hepatic lobe containing multiple fungating masses and associated peripheral bile duct dilatation (arrow in a). (c) Photograph of the resected specimen shows fungating tumors. Histopathologic findings confirmed the diagnosis.

View larger version (100K): [in a new window]   Figure 4c.  Papillary adenocarcinoma in a 63-year-old man who presented with epigastric pain. (a, b) Transverse contrast-enhanced CT images (a at a level higher than b) show aneurysmal dilatation of the lateral segmental bile ducts of the left hepatic lobe containing multiple fungating masses and associated peripheral bile duct dilatation (arrow in a). (c) Photograph of the resected specimen shows fungating tumors. Histopathologic findings confirmed the diagnosis.

View larger version (115K): [in a new window]   Figure 5a.  Papillary adenocarcinoma in a 71-year-old man with no abdominal symptoms. (a) Transverse contrast-enhanced portal phase CT image shows aneurysmally dilated bile ducts in the lateral segment of the left hepatic lobe and small intraductal masses (arrow). Bile ducts in the medial segments of the left and right hepatic lobes, as well as the extrahepatic ducts, are not dilated. (b) Sonogram of the left hepatic lobe, obtained during work-up for lung cancer staging, shows a large complex solid mass (arrows) in the aneurysmally dilated bile ducts. Histopathologic findings confirmed the diagnosis.

View larger version (132K): [in a new window]   Figure 5b.  Papillary adenocarcinoma in a 71-year-old man with no abdominal symptoms. (a) Transverse contrast-enhanced portal phase CT image shows aneurysmally dilated bile ducts in the lateral segment of the left hepatic lobe and small intraductal masses (arrow). Bile ducts in the medial segments of the left and right hepatic lobes, as well as the extrahepatic ducts, are not dilated. (b) Sonogram of the left hepatic lobe, obtained during work-up for lung cancer staging, shows a large complex solid mass (arrows) in the aneurysmally dilated bile ducts. Histopathologic findings confirmed the diagnosis.

View larger version (139K): [in a new window]   Figure 6a.  Papillary tumor of borderline malignancy in a 48-year-old woman who presented with abdominal pain and intermittent fever and chills. (a) Transverse contrast-enhanced portal phase CT image shows severe dilatation of the left and right intrahepatic bile ducts and marked dilatation of the extrahepatic bile ducts but no mucin or tumor. Note the disproportionately greater dilatation of the left hepatic bile ducts. (b) Sonogram shows severe dilatation of the intra- and extrahepatic bile ducts (CBD), which have diameters of 1.5-2.5 cm, but no evidence of mucin or tumor in the dilated ducts. (c) ERCP image shows severe dilatation of the biliary tree, especially the left hepatic ducts, and multiple cordlike filling defects (straight arrow) that represent mucin in the extrahepatic bile ducts. These defects were only minimally altered by forceful injection of contrast material into the ducts. Note also the oval filling defect (curved arrow), which indicates the presence of a nodule in the lateral segmental bile duct of the left hepatic lobe. At surgery, a papillary tumor with a volume of 1.2 x 1.0 x 1.0 cm was found in the left intrahepatic duct, and a large amount of mucin was found in the dilated extrahepatic bile ducts.

View larger version (137K): [in a new window]   Figure 6b.  Papillary tumor of borderline malignancy in a 48-year-old woman who presented with abdominal pain and intermittent fever and chills. (a) Transverse contrast-enhanced portal phase CT image shows severe dilatation of the left and right intrahepatic bile ducts and marked dilatation of the extrahepatic bile ducts but no mucin or tumor. Note the disproportionately greater dilatation of the left hepatic bile ducts. (b) Sonogram shows severe dilatation of the intra- and extrahepatic bile ducts (CBD), which have diameters of 1.5-2.5 cm, but no evidence of mucin or tumor in the dilated ducts. (c) ERCP image shows severe dilatation of the biliary tree, especially the left hepatic ducts, and multiple cordlike filling defects (straight arrow) that represent mucin in the extrahepatic bile ducts. These defects were only minimally altered by forceful injection of contrast material into the ducts. Note also the oval filling defect (curved arrow), which indicates the presence of a nodule in the lateral segmental bile duct of the left hepatic lobe. At surgery, a papillary tumor with a volume of 1.2 x 1.0 x 1.0 cm was found in the left intrahepatic duct, and a large amount of mucin was found in the dilated extrahepatic bile ducts.

View larger version (145K): [in a new window]   Figure 6c.  Papillary tumor of borderline malignancy in a 48-year-old woman who presented with abdominal pain and intermittent fever and chills. (a) Transverse contrast-enhanced portal phase CT image shows severe dilatation of the left and right intrahepatic bile ducts and marked dilatation of the extrahepatic bile ducts but no mucin or tumor. Note the disproportionately greater dilatation of the left hepatic bile ducts. (b) Sonogram shows severe dilatation of the intra- and extrahepatic bile ducts (CBD), which have diameters of 1.5-2.5 cm, but no evidence of mucin or tumor in the dilated ducts. (c) ERCP image shows severe dilatation of the biliary tree, especially the left hepatic ducts, and multiple cordlike filling defects (straight arrow) that represent mucin in the extrahepatic bile ducts. These defects were only minimally altered by forceful injection of contrast material into the ducts. Note also the oval filling defect (curved arrow), which indicates the presence of a nodule in the lateral segmental bile duct of the left hepatic lobe. At surgery, a papillary tumor with a volume of 1.2 x 1.0 x 1.0 cm was found in the left intrahepatic duct, and a large amount of mucin was found in the dilated extrahepatic bile ducts.

View larger version (135K): [in a new window]   Figure 7a.  Papillary adenocarcinomatosis in a 70-year-old woman who presented with intermittent abdominal pain, fever, chills, and jaundice. (a) Sagittal single shot fast spin-echo MR cholangiopancreatographic image shows marked dilatation of the extrahepatic ducts and the posterior segmental bile ducts in the right hepatic lobe and mild dilatation of the anterior segmental ducts of the right hepatic lobe and the left hepatic ducts. (b) Transverse T2-weighted fast spin-echo MR cholangiopancreatographic image shows the dilated posterior segmental bile ducts of the right hepatic lobe with their serrated margins (arrows) but no definite mass. (c) Transverse contrast-enhanced CT image shows markedly dilated posterior segmental bile ducts of the right hepatic lobe with some irregularity along the dilated ducts (arrow) but no tumor or mucin. (d) Sonogram of the right hepatic lobe shows no tumor or mucin, but the irregular contours of the dilated posterior segmental duct (arrow) indicate the presence of sessile tumors attached to the bile duct wall. (e) ERCP image shows large elongated filling defects (arrows) that represent mucin in the extrahepatic ducts but does not show the posterior segmental bile ducts of the right hepatic lobe, probably because of obstruction by the mucin plug. (f) Endoscopic image of the papilla of Vater in the descending duodenum shows a patulous papillary orifice from which flows a large amount of greenish-yellow mucin (arrows). Papillary tumors were found in the posterior segmental bile ducts at cholangioscopy. (g) The resected liver specimen shows a sessile papillary tumor (arrow) in the markedly dilated posterior segmental bile ducts of the right hepatic lobe. The intra- and extrahepatic bile ducts were dilated and filled with mucin.

View larger version (102K): [in a new window]   Figure 7b.  Papillary adenocarcinomatosis in a 70-year-old woman who presented with intermittent abdominal pain, fever, chills, and jaundice. (a) Sagittal single shot fast spin-echo MR cholangiopancreatographic image shows marked dilatation of the extrahepatic ducts and the posterior segmental bile ducts in the right hepatic lobe and mild dilatation of the anterior segmental ducts of the right hepatic lobe and the left hepatic ducts. (b) Transverse T2-weighted fast spin-echo MR cholangiopancreatographic image shows the dilated posterior segmental bile ducts of the right hepatic lobe with their serrated margins (arrows) but no definite mass. (c) Transverse contrast-enhanced CT image shows markedly dilated posterior segmental bile ducts of the right hepatic lobe with some irregularity along the dilated ducts (arrow) but no tumor or mucin. (d) Sonogram of the right hepatic lobe shows no tumor or mucin, but the irregular contours of the dilated posterior segmental duct (arrow) indicate the presence of sessile tumors attached to the bile duct wall. (e) ERCP image shows large elongated filling defects (arrows) that represent mucin in the extrahepatic ducts but does not show the posterior segmental bile ducts of the right hepatic lobe, probably because of obstruction by the mucin plug. (f) Endoscopic image of the papilla of Vater in the descending duodenum shows a patulous papillary orifice from which flows a large amount of greenish-yellow mucin (arrows). Papillary tumors were found in the posterior segmental bile ducts at cholangioscopy. (g) The resected liver specimen shows a sessile papillary tumor (arrow) in the markedly dilated posterior segmental bile ducts of the right hepatic lobe. The intra- and extrahepatic bile ducts were dilated and filled with mucin.

View larger version (124K): [in a new window]   Figure 7c.  Papillary adenocarcinomatosis in a 70-year-old woman who presented with intermittent abdominal pain, fever, chills, and jaundice. (a) Sagittal single shot fast spin-echo MR cholangiopancreatographic image shows marked dilatation of the extrahepatic ducts and the posterior segmental bile ducts in the right hepatic lobe and mild dilatation of the anterior segmental ducts of the right hepatic lobe and the left hepatic ducts. (b) Transverse T2-weighted fast spin-echo MR cholangiopancreatographic image shows the dilated posterior segmental bile ducts of the right hepatic lobe with their serrated margins (arrows) but no definite mass. (c) Transverse contrast-enhanced CT image shows markedly dilated posterior segmental bile ducts of the right hepatic lobe with some irregularity along the dilated ducts (arrow) but no tumor or mucin. (d) Sonogram of the right hepatic lobe shows no tumor or mucin, but the irregular contours of the dilated posterior segmental duct (arrow) indicate the presence of sessile tumors attached to the bile duct wall. (e) ERCP image shows large elongated filling defects (arrows) that represent mucin in the extrahepatic ducts but does not show the posterior segmental bile ducts of the right hepatic lobe, probably because of obstruction by the mucin plug. (f) Endoscopic image of the papilla of Vater in the descending duodenum shows a patulous papillary orifice from which flows a large amount of greenish-yellow mucin (arrows). Papillary tumors were found in the posterior segmental bile ducts at cholangioscopy. (g) The resected liver specimen shows a sessile papillary tumor (arrow) in the markedly dilated posterior segmental bile ducts of the right hepatic lobe. The intra- and extrahepatic bile ducts were dilated and filled with mucin.

View larger version (129K): [in a new window]   Figure 7d.  Papillary adenocarcinomatosis in a 70-year-old woman who presented with intermittent abdominal pain, fever, chills, and jaundice. (a) Sagittal single shot fast spin-echo MR cholangiopancreatographic image shows marked dilatation of the extrahepatic ducts and the posterior segmental bile ducts in the right hepatic lobe and mild dilatation of the anterior segmental ducts of the right hepatic lobe and the left hepatic ducts. (b) Transverse T2-weighted fast spin-echo MR cholangiopancreatographic image shows the dilated posterior segmental bile ducts of the right hepatic lobe with their serrated margins (arrows) but no definite mass. (c) Transverse contrast-enhanced CT image shows markedly dilated posterior segmental bile ducts of the right hepatic lobe with some irregularity along the dilated ducts (arrow) but no tumor or mucin. (d) Sonogram of the right hepatic lobe shows no tumor or mucin, but the irregular contours of the dilated posterior segmental duct (arrow) indicate the presence of sessile tumors attached to the bile duct wall. (e) ERCP image shows large elongated filling defects (arrows) that represent mucin in the extrahepatic ducts but does not show the posterior segmental bile ducts of the right hepatic lobe, probably because of obstruction by the mucin plug. (f) Endoscopic image of the papilla of Vater in the descending duodenum shows a patulous papillary orifice from which flows a large amount of greenish-yellow mucin (arrows). Papillary tumors were found in the posterior segmental bile ducts at cholangioscopy. (g) The resected liver specimen shows a sessile papillary tumor (arrow) in the markedly dilated posterior segmental bile ducts of the right hepatic lobe. The intra- and extrahepatic bile ducts were dilated and filled with mucin.

View larger version (125K): [in a new window]   Figure 7e.  Papillary adenocarcinomatosis in a 70-year-old woman who presented with intermittent abdominal pain, fever, chills, and jaundice. (a) Sagittal single shot fast spin-echo MR cholangiopancreatographic image shows marked dilatation of the extrahepatic ducts and the posterior segmental bile ducts in the right hepatic lobe and mild dilatation of the anterior segmental ducts of the right hepatic lobe and the left hepatic ducts. (b) Transverse T2-weighted fast spin-echo MR cholangiopancreatographic image shows the dilated posterior segmental bile ducts of the right hepatic lobe with their serrated margins (arrows) but no definite mass. (c) Transverse contrast-enhanced CT image shows markedly dilated posterior segmental bile ducts of the right hepatic lobe with some irregularity along the dilated ducts (arrow) but no tumor or mucin. (d) Sonogram of the right hepatic lobe shows no tumor or mucin, but the irregular contours of the dilated posterior segmental duct (arrow) indicate the presence of sessile tumors attached to the bile duct wall. (e) ERCP image shows large elongated filling defects (arrows) that represent mucin in the extrahepatic ducts but does not show the posterior segmental bile ducts of the right hepatic lobe, probably because of obstruction by the mucin plug. (f) Endoscopic image of the papilla of Vater in the descending duodenum shows a patulous papillary orifice from which flows a large amount of greenish-yellow mucin (arrows). Papillary tumors were found in the posterior segmental bile ducts at cholangioscopy. (g) The resected liver specimen shows a sessile papillary tumor (arrow) in the markedly dilated posterior segmental bile ducts of the right hepatic lobe. The intra- and extrahepatic bile ducts were dilated and filled with mucin.

View larger version (137K): [in a new window]   Figure 7f.  Papillary adenocarcinomatosis in a 70-year-old woman who presented with intermittent abdominal pain, fever, chills, and jaundice. (a) Sagittal single shot fast spin-echo MR cholangiopancreatographic image shows marked dilatation of the extrahepatic ducts and the posterior segmental bile ducts in the right hepatic lobe and mild dilatation of the anterior segmental ducts of the right hepatic lobe and the left hepatic ducts. (b) Transverse T2-weighted fast spin-echo MR cholangiopancreatographic image shows the dilated posterior segmental bile ducts of the right hepatic lobe with their serrated margins (arrows) but no definite mass. (c) Transverse contrast-enhanced CT image shows markedly dilated posterior segmental bile ducts of the right hepatic lobe with some irregularity along the dilated ducts (arrow) but no tumor or mucin. (d) Sonogram of the right hepatic lobe shows no tumor or mucin, but the irregular contours of the dilated posterior segmental duct (arrow) indicate the presence of sessile tumors attached to the bile duct wall. (e) ERCP image shows large elongated filling defects (arrows) that represent mucin in the extrahepatic ducts but does not show the posterior segmental bile ducts of the right hepatic lobe, probably because of obstruction by the mucin plug. (f) Endoscopic image of the papilla of Vater in the descending duodenum shows a patulous papillary orifice from which flows a large amount of greenish-yellow mucin (arrows). Papillary tumors were found in the posterior segmental bile ducts at cholangioscopy. (g) The resected liver specimen shows a sessile papillary tumor (arrow) in the markedly dilated posterior segmental bile ducts of the right hepatic lobe. The intra- and extrahepatic bile ducts were dilated and filled with mucin.

View larger version (112K): [in a new window]   Figure 7g.  Papillary adenocarcinomatosis in a 70-year-old woman who presented with intermittent abdominal pain, fever, chills, and jaundice. (a) Sagittal single shot fast spin-echo MR cholangiopancreatographic image shows marked dilatation of the extrahepatic ducts and the posterior segmental bile ducts in the right hepatic lobe and mild dilatation of the anterior segmental ducts of the right hepatic lobe and the left hepatic ducts. (b) Transverse T2-weighted fast spin-echo MR cholangiopancreatographic image shows the dilated posterior segmental bile ducts of the right hepatic lobe with their serrated margins (arrows) but no definite mass. (c) Transverse contrast-enhanced CT image shows markedly dilated posterior segmental bile ducts of the right hepatic lobe with some irregularity along the dilated ducts (arrow) but no tumor or mucin. (d) Sonogram of the right hepatic lobe shows no tumor or mucin, but the irregular contours of the dilated posterior segmental duct (arrow) indicate the presence of sessile tumors attached to the bile duct wall. (e) ERCP image shows large elongated filling defects (arrows) that represent mucin in the extrahepatic ducts but does not show the posterior segmental bile ducts of the right hepatic lobe, probably because of obstruction by the mucin plug. (f) Endoscopic image of the papilla of Vater in the descending duodenum shows a patulous papillary orifice from which flows a large amount of greenish-yellow mucin (arrows). Papillary tumors were found in the posterior segmental bile ducts at cholangioscopy. (g) The resected liver specimen shows a sessile papillary tumor (arrow) in the markedly dilated posterior segmental bile ducts of the right hepatic lobe. The intra- and extrahepatic bile ducts were dilated and filled with mucin.

View larger version (143K): [in a new window]   Figure 8a.  Papillary adenocarcinoma with bile duct rupture in a 54-year-old woman who presented with indigestion and pain in the right upper abdominal quadrant 2 years after undergoing left lateral hepatic segmentectomy for cholangitis and intrahepatic bile duct stones. (a) Transverse contrast-enhanced CT image shows aneurysmal dilatation of the medial segmental bile ducts (black arrows) and a circular fluid collection anterior to the stomach (white arrow). (b) Sonogram of the liver shows severe dilatation of the bile ducts in the left hepatic lobe (arrow). (c) Coronal MR cholangiopancreatographic image shows diffuse dilatation of the biliary tree and aneurysmal dilatation (curved arrow) of bile ducts in the medial segment of the left hepatic lobe, as well as a large oval fluid collection (straight arrow) in the left upper abdominal quadrant. At surgery, a collection of mucin was found that had formed anterior to the stomach as a result of rupture of the dilated left intrahepatic duct. The histopathologic diagnosis was mucin-hypersecreting well-differentiated adenocarcinoma.

View larger version (151K): [in a new window]   Figure 8b.  Papillary adenocarcinoma with bile duct rupture in a 54-year-old woman who presented with indigestion and pain in the right upper abdominal quadrant 2 years after undergoing left lateral hepatic segmentectomy for cholangitis and intrahepatic bile duct stones. (a) Transverse contrast-enhanced CT image shows aneurysmal dilatation of the medial segmental bile ducts (black arrows) and a circular fluid collection anterior to the stomach (white arrow). (b) Sonogram of the liver shows severe dilatation of the bile ducts in the left hepatic lobe (arrow). (c) Coronal MR cholangiopancreatographic image shows diffuse dilatation of the biliary tree and aneurysmal dilatation (curved arrow) of bile ducts in the medial segment of the left hepatic lobe, as well as a large oval fluid collection (straight arrow) in the left upper abdominal quadrant. At surgery, a collection of mucin was found that had formed anterior to the stomach as a result of rupture of the dilated left intrahepatic duct. The histopathologic diagnosis was mucin-hypersecreting well-differentiated adenocarcinoma.

View larger version (126K): [in a new window]   Figure 8c.  Papillary adenocarcinoma with bile duct rupture in a 54-year-old woman who presented with indigestion and pain in the right upper abdominal quadrant 2 years after undergoing left lateral hepatic segmentectomy for cholangitis and intrahepatic bile duct stones. (a) Transverse contrast-enhanced CT image shows aneurysmal dilatation of the medial segmental bile ducts (black arrows) and a circular fluid collection anterior to the stomach (white arrow). (b) Sonogram of the liver shows severe dilatation of the bile ducts in the left hepatic lobe (arrow). (c) Coronal MR cholangiopancreatographic image shows diffuse dilatation of the biliary tree and aneurysmal dilatation (curved arrow) of bile ducts in the medial segment of the left hepatic lobe, as well as a large oval fluid collection (straight arrow) in the left upper abdominal quadrant. At surgery, a collection of mucin was found that had formed anterior to the stomach as a result of rupture of the dilated left intrahepatic duct. The histopathologic diagnosis was mucin-hypersecreting well-differentiated adenocarcinoma.