You are here

Article Text

Article menu

Download PDFPDF

Editor’s quiz: GI snapshot
Biliary dilatation in a 67-year-old woman: seeing is believing
  1. Peng Pan,
  2. Sheng-bing Zhao,
  3. Shuling Wang,
  4. Zhaoshen Li,
  5. Yu Bai
  1. Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
  1. Correspondence to Dr Zhaoshen Li and Dr Yu Bai, Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, 200433, China; li.zhaoshen{at}hotmail.com, baiyu1998{at}hotmail.com

http://dx.doi.org/10.1136/gutjnl-2018-318200

Statistics from Altmetric.com

    Request Permissions

    If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

    Clinical presentation

    A 67-year-old woman presented with paroxysmal epigastric pain for 3 months, without jaundice. She gave a history of cholecystectomy. Physical examination and blood tests were unremarkable. Magnetic resonance cholangiopancreatography showed cystic dilatation of the common bile duct (CBD), intrahepatic and extrahepatic bile duct dilatation and suspicious intrahepatic bile duct stones (figure 1). CT scan showed intrahepatic and extrahepatic bile duct dilatation and multiple intrahepatic bile duct stones (figure 2).

    Figure 1
    Figure 1

    Magnetic resonance cholangiopancreatography showed cystic dilatation of the common bile duct, intrahepatic and extrahepatic bile duct dilatation and suspicious intrahepatic bile duct stones.

    Figure 2
    Figure 2

    CT scan showed intrahepatic and extrahepatic bile duct dilatation and multiple intrahepatic bile duct stones.

    Question

    What is the most likely diagnosis in this case?

    Answer

    Endoscopic retrograde cholangiopancreatography showed dilatation of the CBD (24 mm), amorphous filling defects (figure 3) and a fish-eye sign with much mucus flowing out (figure 4). Cholangiopancreatoscopy showed that the multiple tiny mural nodules involved only the CBD, and mucin clots along with mucus formed the aforesaid filling defects (online supplementary video 1 and 2). Biopsy results proved intestinal-type intraductal papillary mucinous neoplasm (IPMN) with low-grade intraepithelial neoplasia (figure 5).

    Supplemental material

    Figure 3
    Figure 3

    Endoscopic retrograde cholangiopancreatography showed dilatation of the common bile duct and amorphous filling defects.

    Figure 4
    Figure 4

    A fish-eye sign with much mucus flowing out.

    Figure 5
    Figure 5

    Intestinal-type intraductal papillary mucinous neoplasm with low-grade intraepithelial neoplasia (H&E, magnification × 200).

    The causes of biliary dilatation include biliary obstruction secondary to biliary stone, tumour and stricture; cholecystectomy, pancreaticobiliary maljunction, congenital choledochal cyst and so on. In this case, biliary dilatation was caused by mucus accumulation from IPMN of the bile duct (IPMN-B), and intrahepatic biliary stones might be associated with IPMN-B.1 2

    Similar to IPMN of the pancreas, IPMN-B displays mucin-secreting papillary and/or cystic lesions, and can involve intrahepatic and extrahepatic biliary tracts.3 4 However, IPMN-B is rarer and shows a higher tendency to malignant transformation, and warrants more radical surgical treatment.1 4 5 Therefore, as a special subtype of biliary tumour,2 5 IPMN-B should not be ignored in the differential diagnosis of biliary dilatation.

    Supplemental material

    References

    1. ↵
      2. Jung G ,
      3. Park KM ,
      4. Lee SS , et al
      . Long-term clinical outcome of the surgically resected intraductal papillary neoplasm of the bile duct. J Hepatol 2012;57:787–93.doi:10.1016/j.jhep.2012.05.008
      OpenUrlPubMed
    2. ↵
      2. Wang X ,
      3. Cai YQ ,
      4. Chen YH , et al
      . Biliary tract intraductal papillary mucinous neoplasm: report of 19 cases. World J Gastroenterol 2015;21:4261–7.doi:10.3748/wjg.v21.i14.4261
      OpenUrl
    3. ↵
      2. Zen Y ,
      3. Fujii T ,
      4. Itatsu K , et al
      . Biliary papillary tumors share pathological features with intraductal papillary mucinous neoplasm of the pancreas. Hepatology 2006;44:1333–43.doi:10.1002/hep.21387
      OpenUrlCrossRefPubMedWeb of Science
    4. ↵
      2. Minagawa N ,
      3. Sato N ,
      4. Mori Y , et al
      . A comparison between intraductal papillary neoplasms of the biliary tract (BT-IPMNs) and intraductal papillary mucinous neoplasms of the pancreas (P-IPMNs) reveals distinct clinical manifestations and outcomes. Eur J Surg Oncol 2013;39:554–8.doi:10.1016/j.ejso.2013.02.016
      OpenUrl
    5. ↵
      2. Rocha FG ,
      3. Lee H ,
      4. Katabi N , et al
      . Intraductal papillary neoplasm of the bile duct: a biliary equivalent to intraductal papillary mucinous neoplasm of the pancreas? Hepatology 2012;56:1352–60.doi:10.1002/hep.25786
      OpenUrlCrossRefPubMedWeb of Science

    Footnotes

    • PP, S-Z and SW are co-first authors.

    • 35 ZL and YB are co-corresponding authors.

    • Contributors YB was the guarantor of the overall content of the manuscript. ZL planned the study. PP and S-bZ collected the clinical data of the patient. PP and SW drawed up the manuscript. ZL submitted the manuscript.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Patient consent for publication Obtained.