An 81-year-old woman presented with a 2-day history of chills and fever. She had been admitted two years ago with jaundice and fever. On a CT scan, the distal CBD, a large gallbladder (GB) and cystic duct stones were revealed. Urgent endoscopic retrograde cholangiopancreatography (ERCP) to remove the distal CBD stone was performed. Multiple CBD stones were extracted using a basket and balloon sweep. After the stones were removed, there was no filling defect on the CBD during balloon cholangiography. The patient refused cholecystectomy. She was not followed up after discharge from the hospital. On the next presentation, the laboratory tests revealed a slightly elevated aspartate aminotransferase level (45 IU/L) and an increased value of C-reactive protein (15.3 mg/I). The total bilirubin level, the alkaline phosphatase level, the gamma-glutamyltransferase level and the WBC count were all within the normal ranges. The presumed diagnosis was recurrent CBD stones, and an ERCP for recurrent CBD stones was planned. Transabdominal ultrasonography demonstrated a dilated extrahepatic bile duct filled with echogenic lesions that showed posterior acoustic shadowing, which was suggestive of bile duct stones (). On the more medial view of the sagittal sonogram, another mildly dilated extrahepatic bile duct was seen, but no stone was noted (). The sonographic findings led us to presume that the stone-filled aberrant right hepatic duct drained into the common hepatic duct. A contrast-enhanced CT scan was performed using a 64-MDCT scanner (LightSpeed VCT, GE Healthcare, Milwaukee, WI) and it showed two separate extrahepatic bile ducts (). Multiple stones were noted in a posterolaterally located bile duct and these stones extended to right intrahepatic bile ducts. There was a large stone in the GB and the cystic duct joined to a posterolaterally-located extrahepatic bile duct. The MinIP images were obtained on a postprocessing workstation (Advantage Windows workstation [version 4.3], GE Healthcare, Milwaukee, WI). The MinIP image (coronal oblique with a 5.3 mm thickness slab) revealed double extrahepatic bile ducts that combined to create a CBD in the pancreatic head portion with a communicating channel in the hilar portion (). MRCP performed with a 1.5-T Intera scanner (Philips Medical Systems, The Netherlands) failed to depict the precise anatomy of this anomaly due to the impacted stones (). There was no AUPBD on the MRCP. ERC was subsequently performed to remove the multiple stones in one of the double extrahepatic bile ducts. An ERC image also disclosed duplication of the extrahepatic bile duct with multiple stones in the posterolaterally located duct and the right intrahepatic ducts (). However, we failed to gain access to the right CBD and to remove the CBD stones.\nTo remove the remnant stones, duct exploration with insertion of a T-tube and cholecystectomy was performed. On a cholangiogram obtained during the subsequent operation, there was no evidence of remnant stones in the bile ducts (). The patient's postoperative recovery was uneventful.
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 ).