A 74-year-old male presented with jaundice for one month associated with generalized pruritus, epigastric pain, anorexia, and weight loss. On clinical examination, the patient was thin built and icteric with palpable gall bladder.\nLiver function test was consistent with obstructive jaundice with total bilirubin of 154 μmol/l, direct of 152 μmol/l, SGOT of 147 U/l, SGPT of 67 U/l, and ALP of 731 U/l.\nTransabdominal ultrasonography revealed hepatomegaly, moderately dilated IHBD and CBD, and distended gall bladder.\nContrast-enhanced CT of the abdomen with pancreas specific protocol revealed enhancing soft tissue density in the distal common bile duct with upstream dilatation of the CBD, CHD, and IHBD.\nWith the diagnosis of distal cholangiocarcinoma, the patient underwent Whipple's pancreaticoduodenectomy. After dividing the common hepatic duct, two openings were appreciated indicating that the division of common hepatic duct occurred at the confluence. However, on further evaluation, it was appreciated that the confluence was intact and it was the septum in the CHD that was giving the false impression. On detailed evaluation of the resected specimen, a septum extending from the hilum with cystic duct opening on the right side () to the distal end of the bile duct was appreciated, suggesting duplication of the common bile duct. However, the septum was not extending up to the papilla ().\nThis anatomical variation was not appreciated in the imaging preoperatively. A retrospective evaluation of the cross-sectional imaging revealed an incomplete septum extending from the hilum to the distal end of the common bile duct (Figures and ).
A 61-year-old man was admitted to our hospital because of abdominal discomfort since 3 days. He had been in good health without any previous medical history of note. About 23 years ago, he had undergone primary repair of bowel rupture. Physical examination did not show any abnormalities. Initial laboratory data showed elevated serum total bilirubin 1.48 mg/dL, serum aspartate aminotransferase 980 IU/L, serum alanine transaminase 274 IU/L, and serum C-reactive protein 10.8 mg/L. Serum amylase and lipase were within normal limits. Serum was negative for hepatitis B and C markers. Abdominal computed tomography (CT) scan showed multiple CBD stones with dilated bile duct and MPD. On esophagogastroduodenoscopy, the major papilla of Vater was not found in the second duodenal portion. It was finally located in the duodenal bulb (). Endoscopic retrograde cholangiopancreatography (ERCP) was successfully performed via cannulation of the ectopic opening in the duodenal bulb. Dilated CBD with multiple stones was directly visualized radiographically () by injecting contrast media via the orifice. The patient underwent dilatation of the papilla with a balloon catheter (CRE wire-guided balloon dilator 12 to 15 mm; Boston Scientific, Marlborough, MA, USA), and a basket was used to remove the stones (). He was discharged without complications after the procedure.