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 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.