A 52-year-old woman, a previously diagnosed case of cryptogenic cirrhosis, presented with progressive worsening of jaundice and unrelenting right upper quadrant abdominal pain. Previously, her work-up for known etiologies of chronic liver disease (including hepatitis viral serology, autoantibodies such as antinuclear and antismooth muscle antibodies, serum ferritin, and ceruloplasmin levels) were negative. At present admission, her liver biochemistry revealed total, direct, and indirect bilirubin of 7.8, 4.1, and 3.7 mg/dL, respectively. Serum alkaline phosphatase was elevated at 264 IU/L, whereas alanine aminotransferase and aspartate aminotransferase were only marginally raised. Ultrasonography of abdomen revealed biliary dilatation with suspicion of an intraductal calculus impacted at the ampulla. Interestingly, subsequent magnetic resonance cholangiopancreatography (MRCP) revealed duplication of the extrahepatic bile duct []. The duplicated bile ducts were running parallel and were seen to reunite into a common channel at the level of the head of the pancreas consistent with type-Va double common bile duct according to Choi et al. Additionally, a filling-defect suggestive of an obstructive calculus was seen in the common channel just above the ampulla causing obstruction and upstream biliary dilatation (arrow). No associated anomaly of the gallbladder was evident. The cystic duct was seen inserting into the right-sided bile duct. The biliopancreatic junction was unremarkable.
A 60-year-old Middle Eastern male patient with a past medical history of benign prostatic hyperplasia, hypertension, gastroesophageal reflux disease and type 2 diabetes mellitus presented to the emergency department complaining of crampy lower abdominal pain associated with an unintentional 40 pounds weight loss over 4 months. A magnetic resonance imaging (MRI) of the abdomen with intravenous contrast demonstrated a heterogeneous solid pancreatic uncinate mass (3.9 × 3.2 cm) with a duplicated common bile duct ().\nA subsequent endoscopic ultrasound (EUS) confirmed a large heterogeneous hypoechoic mass with irregular borders and cystic areas in the uncinate process of the pancreas. The distal CBD appeared mildly dilated with two extrahepatic bile ducts consistent with type II accessory common bile duct (ACBD). The accessory bile duct provided a conduit for the deposition of bile in the pancreatic head where it terminated. Subsequent inflammation progressed to metaplastic changes confirmed by a fine needle aspiration (FNA) via trangastric approach. The atypical cells of metaplasia found in the pancreatic head were confirmed to be pancreatic adenocarcinoma. Magnetic resonance cholangiopancreatography (MRCP) confirmed the above EUS findings along with multiple enhancing foci also present in the liver. A triple phase computerized tomography (CT) also re-demonstrated an ACBD () with multiple hypervascular hepatic lesions and a soft tissue mass in the pancreatic uncinate process () encasing the superior mesenteric artery (SMA). The patient was eventually discharged for further staging and subsequent chemotherapy at a different institution.