A 63-year-old woman from rural Nepal presented with a history of right upper abdominal pain, epigastric discomfort, bloating, and dyspepsia for 4 years, followed by intermittent fever and jaundice for a month. She had an increase in severity of pain, yellowish discoloration of body, vomiting, and fever for 1 week but had no history of anorexia or weight loss. She had no significant past medical and surgical history. On general examination she had icterus. Her vital parameters were within the normal range. An examination of her abdomen revealed a non-distended soft abdomen with negative Murphy’s sign and her gall bladder was not palpable.\nBiochemical parameters showed hemoglobin 13.4 gm/dl, total leukocyte count 12,600/mm3, platelets 158,000/mm3, total bilirubin 7.9 mg/dl, direct bilirubin 5.4 mg/dl, alanine aminotransferase (ALT) 196 U/L, aspartate aminotransferase (AST) 146 U/L, alkaline phosphatase (ALP) 273 U/L, serum amylase 50 U/L, and lipase 100 U/L. An abdominal ultrasonogram showed multiple calculi in her gallbladder (largest 6 mm), dilated common bile duct (CBD) measuring 13 mm with dilated intrahepatic biliary ducts (IHBDs), and suspected calculi/mass in distal CBD. A contrast-enhanced computed tomography (CECT) scan of her abdomen revealed similar findings and could not differentiate mass or stone in distal CBD. Endoscopic retrograde cholangiopancreatography (ERCP) was planned with the aim of extracting the stone and, if present, a biopsy from the mass. ERCP was unsuccessful on account of difficult anatomy. Magnetic resonance cholangiopancreatography (MRCP) reported the following: IHBDs from the right lobe of the liver drained into the right hepatic duct that formed a separate CBD with the cystic duct opening into it; the IHBDs from the left lobe of the liver drained into the left hepatic duct that formed a separate CBD. Both CBDs appeared mildly dilated proximally and descended separately until a point where a stone was noted. Below this point, the CBD could not be traced so the type of anomaly was inconclusive (Fig. ).\nDue to radiological findings that were suspicious of double CBD (DCBD), our patient was then planned for exploratory laparotomy to assess and confirm the radiological findings, and for definitive diagnosis and treatment of the condition. Intraoperative findings were contracted gall bladder with multiple tiny calculi, two separate draining bile ducts, which were fused just before opening to the ampulla, common duct with a calculus of 1 × 1 cm2, and cystic duct opening into the right duct (Fig. ). So the diagnosis of type Va DCBD with cholelithiasis and choledocholithiasis was made. Following this, cholecystectomy was done, the common duct was explored and the stone was extracted. The right duct was divided just proximal to the opening of the cystic duct and the left duct was also divided at the same level. After closing distal common bile duct stump, reconstruction was done by hepatic ductoplasty (joining two ducts) with hepaticojejunostomy in Roux-en-Y fashion. Her postoperative period was uneventful and she was discharged after 1 week and was doing well at 6-month follow-up.\nHistologic examination of the resected specimens revealed chronic inflammatory changes in the gallbladder and common bile duct with no evidence of malignancy.
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.