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Image of the Month
Image of the Month David M. Warshauer, Section Editor
Question: A 63-year-old man presented with a 2-month history of intermittent abdominal pain. Ultrasonography performed at a local clinic disclosed a single stone in the gallbladder. There was no nausea or vomiting. Vital signs were normal. On physical examination, the abdomen was flat and soft without tenderness. There was no organomegaly. Initial blood test revealed normal white cell count (4300/L), bilirubin (0.7 mg/dL), alkaline phosphatase (53 U/L), serum alanine aminotransferase (18 U/L), and serum aspartate aminotransferase (24 U/L). Serum ␥-glutamil transferase was elevated (155 U/L). Further ultrasonography revealed castlike, nonshadowing, echogenic material filling a segment (about 3-cm long) of the extrahepatic duct (Figure A, arrows). Computed tomography showed segmental soft tissue mass within the extrahepatic duct (Figure B, arrow) associated with mild dilatation of the bile ducts proximal to the lesion. There was a 1.2-cm single calcified stone in the gallbladder. An endoscopic retrograde cholangiogram showed tiny filling defects and serrated appearance of the proximal segment of the extrahepatic duct (Figure C, arrows). On the basis of impression of extrahepatic stones, a stone basket was introduced to retrieve the “stones.” Fragments of “stones” or debris were retrieved (Figure D, arrow). Cytology was performed.
After discussion with surgeon, the extrahepatic bile duct and the gallbladder were resected and Roux-en-Y hepaticojejunostomy was performed. What is the diagnosis? Look on page 1934 for the answer and see the Gastroenterology website (http://www.gastrojournal. org) for more information on submitting your favorite image to Image of the Month.
JAE HOON LIM, MD* MYUNG-HWAN KIM, MD‡ *Department of Radiology Sungkyunkwan University School of Medicine Samsung Medical Center Seoul, Korea ‡ Department of Internal Medicine Asan Medical Center Seoul, Korea © 2006 by the American Gastroenterological Association Institute
0016-5085/06/$32.00 doi:10.1053/j.gastro.2006.03.052
GASTROENTEROLOGY 2006;130:1563
1934
IMAGE OF THE MONTH
GASTROENTEROLOGY Vol. 130, No. 6
Answer to the Image of the Month Question (page 1563): Biliary Papillomatosis The diagnosis is extrahepatic biliary papillomatosis. Cytologic examination of the debris at the time of ERCP revealed fragments of papillary adenoma. Resected extrahepatic duct disclosed papillary adenomatosis (Figure E). Papillary tumor of the bile duct is a distinctive pathologic entity characterized by the presence of intraluminal papillary tumor within the bile duct associated with partial bile duct obstruction.1,2 The tumor is sessile, polypoid, or castlike and is characterized by the presence of innumerable papillary frondlike infoldings comprised of proliferations of columnar epithelial cells around the slender fibrovascular stalks that are supported by the connective tissue of the lamina propria.1 Occasionally, tumor spreads superficially along a variable length of the bile duct (papillomatosis). The tumor is friable and sloughed frequently.3 Because the bile ducts are partially obstructed and the sloughed tumor fragments occlude the bile duct intermittently, clinical symptoms, signs, and laboratory tests mimic those of bile duct stones.3 Imaging findings may also mimic stone disease,3,4 resulting in frequent misdiagnosis. References 1. Taguchi J, Yasunaga M, Kojiro M, et al. Intrahepatic and extrahepatic biliary papillomatosis. Arch Pathol Lab Med 1993;117:944 –947. 2. Lam CM, Yeun ST, Yuen WK, Fan ST. Biliary papillomatosis. Br J Surg 1996;83:1715–1716. 3. Lim JH, Kim M-H, Kim TK, et al. Papillary neoplasms of the bile duct that mimic biliary stone disease. Radiographics 2003;23:447– 455. 4. Kawakatsu M, Vilgrain V, Zins M, et al. Radiologic features of papillary adenoma and papillomatosis of the biliary tract. Abdom Imaging 1997;22:87–90. For submission instructions, please see the Gastroenterology website (http://www.gastrojournal.org).
Question: A 63-year-old man presented with a 2-month history of intermittent abdominal pain. Ultrasonography performed at a local clinic disclosed a single stone in the gallbladder. There was no nausea or vomiting. Vital signs were normal. On physical examination, the abdomen was flat and soft without tenderness. There was no organomegaly. Initial blood test revealed normal white cell count (4300/L), bilirubin (0.7 mg/dL), alkaline phosphatase (53 U/L), serum alanine aminotransferase (18 U/L), and serum aspartate aminotransferase (24 U/L). Serum ␥-glutamil transferase was elevated (155 U/L). Further ultrasonography revealed castlike, nonshadowing, echogenic material filling a segment (about 3-cm long) of the extrahepatic duct (Figure A, arrows). Computed tomography showed segmental soft tissue mass within the extrahepatic duct (Figure B, arrow) associated with mild dilatation of the bile ducts proximal to the lesion. There was a 1.2-cm single calcified stone in the gallbladder. An endoscopic retrograde cholangiogram showed tiny filling defects and serrated appearance of the proximal segment of the extrahepatic duct (Figure C, arrows). On the basis of impression of extrahepatic stones, a stone basket was introduced to retrieve the “stones.” Fragments of “stones” or debris were retrieved (Figure D, arrow). Cytology was performed.
After discussion with surgeon, the extrahepatic bile duct and the gallbladder were resected and Roux-en-Y hepaticojejunostomy was performed. What is the diagnosis? Look on page 1934 for the answer and see the Gastroenterology website (http://www.gastrojournal. org) for more information on submitting your favorite image to Image of the Month.
JAE HOON LIM, MD* MYUNG-HWAN KIM, MD‡ *Department of Radiology Sungkyunkwan University School of Medicine Samsung Medical Center Seoul, Korea ‡ Department of Internal Medicine Asan Medical Center Seoul, Korea © 2006 by the American Gastroenterological Association Institute
0016-5085/06/$32.00 doi:10.1053/j.gastro.2006.03.052
GASTROENTEROLOGY 2006;130:1563
1934
IMAGE OF THE MONTH
GASTROENTEROLOGY Vol. 130, No. 6
Answer to the Image of the Month Question (page 1563): Biliary Papillomatosis The diagnosis is extrahepatic biliary papillomatosis. Cytologic examination of the debris at the time of ERCP revealed fragments of papillary adenoma. Resected extrahepatic duct disclosed papillary adenomatosis (Figure E). Papillary tumor of the bile duct is a distinctive pathologic entity characterized by the presence of intraluminal papillary tumor within the bile duct associated with partial bile duct obstruction.1,2 The tumor is sessile, polypoid, or castlike and is characterized by the presence of innumerable papillary frondlike infoldings comprised of proliferations of columnar epithelial cells around the slender fibrovascular stalks that are supported by the connective tissue of the lamina propria.1 Occasionally, tumor spreads superficially along a variable length of the bile duct (papillomatosis). The tumor is friable and sloughed frequently.3 Because the bile ducts are partially obstructed and the sloughed tumor fragments occlude the bile duct intermittently, clinical symptoms, signs, and laboratory tests mimic those of bile duct stones.3 Imaging findings may also mimic stone disease,3,4 resulting in frequent misdiagnosis. References 1. Taguchi J, Yasunaga M, Kojiro M, et al. Intrahepatic and extrahepatic biliary papillomatosis. Arch Pathol Lab Med 1993;117:944 –947. 2. Lam CM, Yeun ST, Yuen WK, Fan ST. Biliary papillomatosis. Br J Surg 1996;83:1715–1716. 3. Lim JH, Kim M-H, Kim TK, et al. Papillary neoplasms of the bile duct that mimic biliary stone disease. Radiographics 2003;23:447– 455. 4. Kawakatsu M, Vilgrain V, Zins M, et al. Radiologic features of papillary adenoma and papillomatosis of the biliary tract. Abdom Imaging 1997;22:87–90. For submission instructions, please see the Gastroenterology website (http://www.gastrojournal.org).