DOI: 10.1148/rg.274065047
CT Evaluation of the Bulging Papilla with Endoscopic Correlation1
Suk Kim, MD,
Nam Kyung Lee, MD,
Jun Woo Lee, MD,
Chang Won Kim, MD,
Suck Hong Lee, MD,
Gwang Ha Kim, MD, and
Dae Hwan Kang, MD
1 From the Departments of Diagnostic Radiology (S.K., N.K.L., J.W.L., C.W.K., S.H.L.) and Gastrointestinal Internal Medicine (G.H.K., D.H.K.), Pusan National University Hospital, Pusan National University School of Medicine, 1-10 Ami-Dong, Seo-gu, Busan 602-739, Republic of Korea; and the Medical Research Institute, Pusan National College of Medicine, Busan, Republic of Korea (S.K., J.W.L., G.H.K., D.H.K.). Recipient of a Cum Laude award for an education exhibit at the 2005 RSNA Annual Meeting. Received March 30, 2006; revision requested July 26 and received August 31; accepted September 1. Supported by Medical Research Institute grants from Pusan National University.
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Figure 1a. (a) Drawing illustrates papillitis with a distal common bile duct (CBD) stone. Bulging of the papilla is due to inflammation in the ampulla of Vater, which is precipitated by mechanical irritation from choledocholithiasis. (b) Drawing illustrates branch duct type IPMT. Protrusion of the major papilla into the duodenal lumen, as well as mild and symmetric wall thickening, is frequently seen. (c) Drawing illustrates ampullary carcinoma (exposed type). Note the asymmetric and irregularly thickened wall at the distal margin of the pancreaticobiliary junction that obliterates the lumen, along with enlargement of the major duodenal papilla.
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Figure 1b. (a) Drawing illustrates papillitis with a distal common bile duct (CBD) stone. Bulging of the papilla is due to inflammation in the ampulla of Vater, which is precipitated by mechanical irritation from choledocholithiasis. (b) Drawing illustrates branch duct type IPMT. Protrusion of the major papilla into the duodenal lumen, as well as mild and symmetric wall thickening, is frequently seen. (c) Drawing illustrates ampullary carcinoma (exposed type). Note the asymmetric and irregularly thickened wall at the distal margin of the pancreaticobiliary junction that obliterates the lumen, along with enlargement of the major duodenal papilla.
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Figure 1c. (a) Drawing illustrates papillitis with a distal common bile duct (CBD) stone. Bulging of the papilla is due to inflammation in the ampulla of Vater, which is precipitated by mechanical irritation from choledocholithiasis. (b) Drawing illustrates branch duct type IPMT. Protrusion of the major papilla into the duodenal lumen, as well as mild and symmetric wall thickening, is frequently seen. (c) Drawing illustrates ampullary carcinoma (exposed type). Note the asymmetric and irregularly thickened wall at the distal margin of the pancreaticobiliary junction that obliterates the lumen, along with enlargement of the major duodenal papilla.
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Figure 2. Endoscopic image shows the normal major duodenal papilla (arrow) as an oval protuberance at the intersection of a covering transverse mucosal fold (T) and the longitudinal folds (*).
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Figure 3a. (a) On a contrast-enhanced CT scan, the normal major duodenal papilla (arrow) can barely be distinguished from the surrounding duodenal mucosal folds, which was true in most cases in our study. (b) Contrast-enhanced CT scan shows the papilla (arrow) as a protuberance less than 10 mm in diameter with enhancement comparable to that of the adjacent duodenal mucosa, a finding that is seen less frequently than that in a. The targetlike enhancement of the normal papilla may be confused with a stone surrounded by low-attenuation bile.
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Figure 3b. (a) On a contrast-enhanced CT scan, the normal major duodenal papilla (arrow) can barely be distinguished from the surrounding duodenal mucosal folds, which was true in most cases in our study. (b) Contrast-enhanced CT scan shows the papilla (arrow) as a protuberance less than 10 mm in diameter with enhancement comparable to that of the adjacent duodenal mucosa, a finding that is seen less frequently than that in a. The targetlike enhancement of the normal papilla may be confused with a stone surrounded by low-attenuation bile.
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Figure 4a. Bulging papilla from a distal CBD stone in a 48-year-old man. (a) Unenhanced CT scan shows a high-attenuation stone (arrow) in the intrapancreatic portion of the distal bile duct. (b) On a contrast-enhanced CT scan obtained at the same level, the stone is surrounded by inflammatory change in the ampulla of Vater, which causes bulging of the papilla with increased targetlike enhancement (arrow). (c) Endoscopic image obtained after stone removal shows pus leaking from the severely inflamed papilla.
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Figure 4b. Bulging papilla from a distal CBD stone in a 48-year-old man. (a) Unenhanced CT scan shows a high-attenuation stone (arrow) in the intrapancreatic portion of the distal bile duct. (b) On a contrast-enhanced CT scan obtained at the same level, the stone is surrounded by inflammatory change in the ampulla of Vater, which causes bulging of the papilla with increased targetlike enhancement (arrow). (c) Endoscopic image obtained after stone removal shows pus leaking from the severely inflamed papilla.
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Figure 4c. Bulging papilla from a distal CBD stone in a 48-year-old man. (a) Unenhanced CT scan shows a high-attenuation stone (arrow) in the intrapancreatic portion of the distal bile duct. (b) On a contrast-enhanced CT scan obtained at the same level, the stone is surrounded by inflammatory change in the ampulla of Vater, which causes bulging of the papilla with increased targetlike enhancement (arrow). (c) Endoscopic image obtained after stone removal shows pus leaking from the severely inflamed papilla.
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Figure 5a. Bulging papilla from an impacted stone in the ampulla of Vater in a 37-year-old woman. (a) Contrast-enhanced coronal reformatted CT image shows bulging of the papilla (arrow) caused by an impacted stone in the ampulla of Vater, along with upstream bile duct dilatation. (b) Endoscopic image also shows marked bulging of the papilla caused by the impacted stone in the ampulla of Vater.
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Figure 5b. Bulging papilla from an impacted stone in the ampulla of Vater in a 37-year-old woman. (a) Contrast-enhanced coronal reformatted CT image shows bulging of the papilla (arrow) caused by an impacted stone in the ampulla of Vater, along with upstream bile duct dilatation. (b) Endoscopic image also shows marked bulging of the papilla caused by the impacted stone in the ampulla of Vater.
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Figure 6a. Bulging papilla from an isoattenuating CBD stone in a 27-year-old woman. (a) Contrast-enhanced CT scan shows mild bulging of the papilla with increased targetlike enhancement (arrow). (b) ERCP image shows a filling defect (arrowhead) in the distal CBD. (c) Endoscopic image shows bulging of the papilla with erythema.
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Figure 6b. Bulging papilla from an isoattenuating CBD stone in a 27-year-old woman. (a) Contrast-enhanced CT scan shows mild bulging of the papilla with increased targetlike enhancement (arrow). (b) ERCP image shows a filling defect (arrowhead) in the distal CBD. (c) Endoscopic image shows bulging of the papilla with erythema.
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Figure 6c. Bulging papilla from an isoattenuating CBD stone in a 27-year-old woman. (a) Contrast-enhanced CT scan shows mild bulging of the papilla with increased targetlike enhancement (arrow). (b) ERCP image shows a filling defect (arrowhead) in the distal CBD. (c) Endoscopic image shows bulging of the papilla with erythema.
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Figure 7a. Bulging papilla from papillitis in a 35-year-old man. The papillitis may have been due to a recently passed stone. (a) Contrast-enhanced CT scan shows bulging of the papilla with intense mucosal enhancement (arrow), but there is no evidence of stones. (b) Endoscopic image shows the edematous papilla with petechia. As at CT, however, there was no evidence of stones at ERCP.
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Figure 7b. Bulging papilla from papillitis in a 35-year-old man. The papillitis may have been due to a recently passed stone. (a) Contrast-enhanced CT scan shows bulging of the papilla with intense mucosal enhancement (arrow), but there is no evidence of stones. (b) Endoscopic image shows the edematous papilla with petechia. As at CT, however, there was no evidence of stones at ERCP.
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Figure 8. Bulging papilla from acute pancreatitis in a 46-year-old man. Contrast-enhanced CT scan shows bulging of the papilla with increased targetlike enhancement (arrow) and marked submucosal edema. A moderate amount of inflammatory fluid surrounding a mildly enlarged pancreas is indicative of acute pancreatitis.
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Figure 9a. Bulging papilla from periampullary diverticulum in a 61-year-old man. Contrast-enhanced CT scans demonstrate a huge periampullary diverticulum (* in a) and bulging of the papilla (arrow in a). Mild dilatation of the upstream bile duct caused by papillary stenosis is also seen (arrowhead in b).
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Figure 9b. Bulging papilla from periampullary diverticulum in a 61-year-old man. Contrast-enhanced CT scans demonstrate a huge periampullary diverticulum (* in a) and bulging of the papilla (arrow in a). Mild dilatation of the upstream bile duct caused by papillary stenosis is also seen (arrowhead in b).
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Figure 10a. Bulging patulous papilla from IPMT in a 52-year-old man. (a–c) Contrast-enhanced axial (a) and coronal reformatted (b, c) CT images show cystic dilated branch ducts (arrowhead in c), a dilated MPD (arrow in b), and bulging of the papilla with faint enhancement (arrow in a). (d) Endoscopic image reveals jellylike mucin leaking from the papilla.
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Figure 10b. Bulging patulous papilla from IPMT in a 52-year-old man. (a–c) Contrast-enhanced axial (a) and coronal reformatted (b, c) CT images show cystic dilated branch ducts (arrowhead in c), a dilated MPD (arrow in b), and bulging of the papilla with faint enhancement (arrow in a). (d) Endoscopic image reveals jellylike mucin leaking from the papilla.
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Figure 10c. Bulging patulous papilla from IPMT in a 52-year-old man. (a–c) Contrast-enhanced axial (a) and coronal reformatted (b, c) CT images show cystic dilated branch ducts (arrowhead in c), a dilated MPD (arrow in b), and bulging of the papilla with faint enhancement (arrow in a). (d) Endoscopic image reveals jellylike mucin leaking from the papilla.
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Figure 10d. Bulging patulous papilla from IPMT in a 52-year-old man. (a–c) Contrast-enhanced axial (a) and coronal reformatted (b, c) CT images show cystic dilated branch ducts (arrowhead in c), a dilated MPD (arrow in b), and bulging of the papilla with faint enhancement (arrow in a). (d) Endoscopic image reveals jellylike mucin leaking from the papilla.
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Figure 12a. Bulging papilla from exposed (exophytic) type ampullary carcinoma in a 56-year-old woman. (a) Contrast-enhanced CT scan shows a polypoid lesion (arrow) at the ampulla of Vater. Note the bulging, irregularly contoured major duodenal papilla, findings that indicate tumoral invasion into the mucosa of the papilla. (b) Endoscopic image demonstrates the bulging papilla with coarse nodularity, a finding that suggests ampullary carcinoma. Adenocarcinoma was confirmed at biopsy.
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Figure 12b. Bulging papilla from exposed (exophytic) type ampullary carcinoma in a 56-year-old woman. (a) Contrast-enhanced CT scan shows a polypoid lesion (arrow) at the ampulla of Vater. Note the bulging, irregularly contoured major duodenal papilla, findings that indicate tumoral invasion into the mucosa of the papilla. (b) Endoscopic image demonstrates the bulging papilla with coarse nodularity, a finding that suggests ampullary carcinoma. Adenocarcinoma was confirmed at biopsy.
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Figure 13a. Bulging papilla from nonexposed (intramural) type ampullary adenocarcinoma in a 53-year-old man. (a) Contrast-enhanced coronal reformatted CT image shows irregularly thickened mucosa of the ampulla obliterating the lumen, but with the mucosa of the major duodenal papilla relatively intact (arrow). (b) Endoscopic image shows a bulging papilla with normal-looking overlying mucosa. Initial biopsy showed chronic inflammation. Repeat biopsy performed 1 month later revealed adenocarcinoma.
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Figure 13b. Bulging papilla from nonexposed (intramural) type ampullary adenocarcinoma in a 53-year-old man. (a) Contrast-enhanced coronal reformatted CT image shows irregularly thickened mucosa of the ampulla obliterating the lumen, but with the mucosa of the major duodenal papilla relatively intact (arrow). (b) Endoscopic image shows a bulging papilla with normal-looking overlying mucosa. Initial biopsy showed chronic inflammation. Repeat biopsy performed 1 month later revealed adenocarcinoma.
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Figure 14a. Bulging papilla from periampullary cancer in a 65-year-old woman. (a) Contrast-enhanced coronal reformatted CT image reveals a periampullary mass (arrow) invading the distal CBD, resulting in upstream bile duct dilatation. (b) Endoscopic image shows an ulceroinfiltrative lesion in the periampullary region. The lesion was confirmed to be adenocarcinoma at biopsy.
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Figure 14b. Bulging papilla from periampullary cancer in a 65-year-old woman. (a) Contrast-enhanced coronal reformatted CT image reveals a periampullary mass (arrow) invading the distal CBD, resulting in upstream bile duct dilatation. (b) Endoscopic image shows an ulceroinfiltrative lesion in the periampullary region. The lesion was confirmed to be adenocarcinoma at biopsy.
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Figure 15a. Bulging papilla from autoimmune pancreatitis in a 54-year-old woman. (a, b) Arterial phase (a) and equilibrium phase (b) CT scans demonstrate a bulging papilla with delayed enhancement (arrow) and diffuse enlargement of the pancreas. The pancreatic parenchyma shows delayed homogeneous enhancement, and a low-attenuation rim (arrowhead) is seen surrounding the pancreas. (c) Endoscopic image shows bulging of the papilla, which has a smooth surface. Lymphocytic infiltration of the papilla was revealed at biopsy.
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Figure 15b. Bulging papilla from autoimmune pancreatitis in a 54-year-old woman. (a, b) Arterial phase (a) and equilibrium phase (b) CT scans demonstrate a bulging papilla with delayed enhancement (arrow) and diffuse enlargement of the pancreas. The pancreatic parenchyma shows delayed homogeneous enhancement, and a low-attenuation rim (arrowhead) is seen surrounding the pancreas. (c) Endoscopic image shows bulging of the papilla, which has a smooth surface. Lymphocytic infiltration of the papilla was revealed at biopsy.
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Figure 15c. Bulging papilla from autoimmune pancreatitis in a 54-year-old woman. (a, b) Arterial phase (a) and equilibrium phase (b) CT scans demonstrate a bulging papilla with delayed enhancement (arrow) and diffuse enlargement of the pancreas. The pancreatic parenchyma shows delayed homogeneous enhancement, and a low-attenuation rim (arrowhead) is seen surrounding the pancreas. (c) Endoscopic image shows bulging of the papilla, which has a smooth surface. Lymphocytic infiltration of the papilla was revealed at biopsy.
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Figure 16a. Choledochocele in a 69-year-old woman. (a) Contrast-enhanced CT scan shows cystic dilatation of the terminal bile duct protruding into the duodenum (arrow). (b) ERCP image obtained after contrast material had been injected under pressure shows obvious cystic bulging of the papilla (arrowhead).
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Figure 16b. Choledochocele in a 69-year-old woman. (a) Contrast-enhanced CT scan shows cystic dilatation of the terminal bile duct protruding into the duodenum (arrow). (b) ERCP image obtained after contrast material had been injected under pressure shows obvious cystic bulging of the papilla (arrowhead).
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Figure 17a. Bulging papilla from GIST (a high-grade malignancy). (a) Contrast-enhanced coronal reformatted CT image shows a slightly enhancing exoenteric mass with some necrotic areas (arrow) in the medial aspect of the third portion of the duodenum. (b) Endoscopic image shows an exophytic ulcerating mass in the proximal part of the third duodenal portion.
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Figure 17b. Bulging papilla from GIST (a high-grade malignancy). (a) Contrast-enhanced coronal reformatted CT image shows a slightly enhancing exoenteric mass with some necrotic areas (arrow) in the medial aspect of the third portion of the duodenum. (b) Endoscopic image shows an exophytic ulcerating mass in the proximal part of the third duodenal portion.
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Figure 18a. Bulging patulous papilla in a 62-year-old woman. (a) Contrast-enhanced CT scan demonstrates a low-attenuation masslike lesion in the uncinate process of the pancreas (arrow), with pneumobilia and air in the pancreatic duct (arrowhead) due to previous sphincterotomy. Pancreatic abscess was proved at sonographically guided core biopsy. (b) Endoscopic image shows two openings in the patulous papilla (*).
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Figure 18b. Bulging patulous papilla in a 62-year-old woman. (a) Contrast-enhanced CT scan demonstrates a low-attenuation masslike lesion in the uncinate process of the pancreas (arrow), with pneumobilia and air in the pancreatic duct (arrowhead) due to previous sphincterotomy. Pancreatic abscess was proved at sonographically guided core biopsy. (b) Endoscopic image shows two openings in the patulous papilla (*).
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Copyright © 2007 by the Radiological Society of North America.
