A 57-year-old man was referred to our hospital for further evaluation of pneumobilia. He was complaining of nausea for 1 month. He had no past medical history of note. On admission, physical examination was unremarkable. Initial laboratory findings were normal. On abdominal CT, diffuse pneumobilia was evident, and a communication was suspected between the duodenal bulb and the extrahepatic bile duct. For confirmation, ERCP was performed. ERCP showed an ectopic opening of the major papilla of Vater in the duodenal bulb (). We cannulated the ectopic opening and injected contrast media via the orifice. We found that the CBD and MPD were communicating with the duodenal bulb (). After 9 months, abdominal CT scan showed focal nodular wall thickening with enhancement of the gallbladder (). Consequently, the patient underwent radical cholecystectomy with hepaticojejunostomy as gallbladder cancer was suspected. Histopathological examination revealed a moderately differentiated adenocarcinoma arising from the gallbladder and extending into the perimuscular connective tissue (). After the operation, he was discharged without complications.
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.