A 71-year-old female presented with right upper quadrat (RUQ) pain associated with vomiting. She has no significant past medical or surgical history. Laboratory results revealed a normal white cell count and liver function tests but a raised C-reactive protein.\nComputerized tomography demonstrated an enhancing soft tissue thickening in the gastric pylorus with soft tissue extension into the left lobe of the liver, invasion of the left intrahepatic bile ducts with obstruction and dilatation of the left sided intra- and extrahepatic biliary tract (). Oesophagogastroduodenoscopy (OGD) showed a pre-pyloric fistula ().\nFurther examination led to a diagnosis of DCBD with a separate left intra- and extrahepatic bile duct with ectopic drainage into the stomach. Magnetic resonance cholangiopancreatography (MRCP) revealed marked left intrahepatic duct (IHD) dilatation. The left IHDs were draining via an aberrant extra-hepatic bile duct into the pre-pyloric region. The left and right hepatic ducts did not communicate. It also demonstrated pancreatic divisum and multiple side branch intra-ductal papillary mucinous neoplasms (IPMN) (). Endoscopic retrograde cholangiopancreatography (ERCP) confirmed the MRCP findings but also revealed an intraluminal-filling defect in the left IHD ( and ).\nShe underwent a left hemi-hepatectomy and a wedge excision of the antrum of the stomach. Intraoperative examination confirmed the radiological findings (–). There were an atrophic left liver lobe and a dilated ACBD draining segments 2–4. The left portal vein crossed anteriorly to the ACBD with the left hepatic artery (LHA) lying medial to it. An accessory LHA was also present within the hepato-gastric ligament. Postoperative recovery was uneventful. Histology showed intraductal papillary neoplasm of the bile duct (IPN-B) with low-grade dysplasia involving both the intra- and extrahepatic bile ducts.
A 77-year-old woman presented to the outpatient department of our hospital complaining of recurrent epigastric pain.\nPatient’s symptoms started a month ago with recurrent episodes, with no history of fever, chills, or vomiting.\nThe patient had a history of laparoscopic cholecystectomy for cholelithiasis 2 years earlier at another hospital. She had undergone endoscopic retrograde cholan-giopancreatography (ERCP) twice for choledocholithiasis before undergoing cholecystectomy.\nThe patient did not have a history of drinking or smoking. There was no remarkable family medical history.\nPhysical examination did not reveal tenderness or signs of peritoneal irrigation, and the bowel sounds were normal. At the outpatient clinic, her temperature was 36.7 °C, pulse rate was 70 beats/min, and blood pressure was 122/82 mm Hg.\nBlood analysis showed normal complete blood cell count, liver function test and C-reactive protein.\nComputed tomography (CT) imaging revealed a dilated CBD that harboured multiple choledocholithiasis (Figure ). After admission, ERCP was subsequently performed, and the stones were extracted using a Dormia basket (MTW Endoskopie, Wesel, Germany) (Figure ) after endoscopic papillary balloon dilatation by a CRETM balloon dilatation catheters (Boston Scientific Corporation, Natick, MA, United States). A 5 Fr endoscopic nasobiliary drainage (ENBD) catheter (ENBD-5, Cook Medical, Bloomington, IN, United States) was inserted at the end of the procedure. A day after the ERCP, tubography via the ENBD catheter was performed to confirm the presence of residual stones in the bile duct. However, no definite filling defects were observed on tubography (Figure ). The patient was discharged without any complications of ERCP. A day after discharge, she visited the emergency department with complaints of severe epigastric pain and fever. Her temperature was 38.2 °C, pulse rate was 79 beats/min, and blood pressure was 149/85 mm Hg. Laboratory findings were suggestive of cholestasis [aspartate aminotransferase, 210 U/L (normal: 0–35 U/L); alanine aminotransferase, 134 U/L (0-35); alkaline phosphatase, 201 U/L (30-120); gamma glutamyl transferase, 184 U/L (9-64); total bilirubin, 2.77 mg/dL (0.3-1.2); direct bilirubin, 1.32 mg/dL (0-0.2); and C-reactive protein 6.91 mg/dL]. A CT scan demonstrated another dilated extrahepatic bile duct draining the right lobe of the liver, which also contained stones in the distal portion (Figure ). An urgent ERCP was performed as the stones were impacted at the ampulla (Figure ), and the stones with pus were retrieved using a balloon catheter (Escort II® Double Lumen Extraction Balloon, Cook Medical, Bloomington, IN, United States). A 10 Fr, 5 cm endoscopic retrograde biliary drainage tube (Cotton-Leung Biliary Stent, Cook Medical, Bloomington, IN, United States) was then placed in the CBD.\nMagnetic resonance cholangiopancreatography (MRCP) was performed to evaluate the delicate structures of the CBD and to check for any remnant stones. MRCP revealed DCBD independently draining the left and right lobes of the liver, that created a short segment intrapancreatic CBD (Figure ) without a communicating channel, that was consistent with the DCBD Type Va as classified by Choi et al[,]. Residual choledocholithiasis was also noted in the right CBD. There was no evidence of anomalous union of the pancreaticobiliary duct on MRCP.