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.
A 54-year-old male presented to a primary care physician with a complaint of indigestion. He underwent gastrofiberscopy, which revealed a small circumferential ulceroinfiltrative ill-defined mucosal lesion at the anterior wall of the antrum. Biopsy specimens were taken from the ulceroinfiltrative lesion, and showed adenocarcinoma. He was diagnosed with gastric cancer and referred to our hospital for an operation. We didn't detect any abnormal findings physically or in the laboratory. Abdominal CT scan showed mild gastric mucosal thickening in the anterior wall of the gastric antrum. We decided to perform laparoscopic assisted distal gastrectomy. During the surgery, we incidentally detected bile leak from the tubular structure around the hepatoduodenal ligament, and therefore converted to open surgery (). We performed intraoperative cholangiogram by cannulizing into the tubular duct, and confirmed that the tubular duct was the accessory bile duct with an ectopic drainage into the stomach, which was connected with the proximal common bile duct and linked with the left intrahepatic duct (). In the specimen, the ACBD was independent of the cancer lesion (). The ACBD was resected afterward. The patient was discharged without complications, and is doing well until now.