Background and study aims: Although abdominal ultrasonography (US) is a good initial screening method for detection of biliary tract disease, we sometimes encounter patients who only have findings of dilatation of the common bile duct (CBD) on US, without specific biliary symptoms or jaundice. This study aimed to evaluate the causes and clinical significance of dilatation of the CBD in patients without biliary symptoms, jaundice, or causative lesions at US.
Patients and methods: A total of 77 patients who had no biliary symptoms and whose internal CBD diameter was more than 7 mm, without definite causative lesions on US, were enrolled. Of these, 49 underwent endoscopic retrograde cholangiopancreatography (ERCP) and 28 underwent follow-up US or computed tomography (CT) instead of ERCP. We excluded patients whose bilirubin level had increased beyond the upper normal level or who had previous history of upper abdominal surgery including cholecystectomy.
Results: The ERCP findings were as follows: no lesion in 20 patients (40.8%), juxtapapillary duodenal diverticulum (JDD) in 11 (22.5%), benign stricture in ten (20.4%), distal CBD mass in two (4.1%), choledochal cyst in two (4.1%), anomalous union of the pancreaticobiliary duct (AUPBD) in two (4.1%), and choledochal cyst with AUPBD in two (4.1%). There were no differences in age or in alkaline phosphatase or gamma-glutamyl transpeptidase (GGT) levels between the patients who had causative lesions revealed at ERCP and those who did not. Among the 28 patients who did not undergo ERCP, 12 had returned to normal and eight had no change in CBD diameter on follow-up US. Among eight patients who underwent CT, there were four with normal findings, one with JDD, and three with suspected choledochal cysts.
Patient then planned for ERCP for biliary drainage for alleviation of her symptoms. Cholangiogram revealed dilated CBD measuring 2.5 cm with horizontal band like filling defect in distal CBD (Figure 4). Dilatation was performed using Soehendra Biliary Dilation Catheter of 7, 8.5 & 10 Fr. 10 Fr X 10 cm stent was placed post dilatation. Serum CA 19-9 was normal.
The physiologic implications of web of the extra hepatic biliary tree are not necessarily the same as for other causes of extra hepatic biliary obstruction. While the web may ultimately cause obstruction, it is likely that forward drainage from the liver will be undisturbed in the vast majority of cases. Initially the patient may be asymptomatic or may present with vague and nonspecific symptoms such as abdominal pain, nausea and vomiting. Early on in the disease process, one may only demonstrate elevations of Transaminase and alkaline Phosphatase, together with ductal dilatation, but without obstructive jaundice.16 However, in the setting of inflammation in the region of the porta hepatis, or the passage of a small calculus, the web will almost certainly become obstructed and result in obstructive jaundice with or without the association of cholangitis. These webs are probably congenital and only present later in life due to an associated abnormality. Histologically, the webs consist of a fibro muscular layer covered by normal epithelium.17
The described associated abnormalities with these webs include anomalous hepatic duct of the caudate lobe and anomalous junction of the pancreato-biliary ductal system.3 Choledochal cyst or hepatic fibrosis are also found in association with cases of Choledochal web.4,5 Congenital CBD web needs to be differentiated from other causes of biliary strictures. In Primary sclerosing cholangitis there are multiple strictures in CBD and are often associated with Inflammatory Bowel Disease.5, 6 iatrogenic structures occur more commonly in common or right hepatic duct. Isolated biliary strictures has also been described in cases of blunt abdominal trauma or radiation exposure to upper abdomen.7,8 Our case represents the first to report EUS characteristics of Choledochal web, with no previous reports till date.
EUS was performed which revealed horizontal hyper echoic structure of 7 mm in distal CBD with dilated proximal CBD, measuring 2.5 cm at porta and intra-pancreatic CBD of 5 mm (Figure 3)
Webs may be partial or complete and the degree of obstruction determines whether patient will be symptomatic or not. Treatment is either Endoscopic dilatation or surgical bypass. 9 Dollar et al. described a congenital web of the CHD in an adult patient, which was not associated with jaundice.10 Chapoy et al. described a similar case to the one described by Dollar et al. but their patient was only 40 months old.11 The association of CHD ‘diaphragms’ and biliary obstruction has been described by both Fisher et al. and Devanesan et al., who postulated that small perforations in these diaphragms allowed some degree of biliary drainage and thus a delayed presentation of obstructive jaundice.12,13 Ravi K et al. In their report mentioned about successful endoscopic therapy of Choledochal web by Balloon Dilatation.14 Kim et al described a case of intra-hepatic Choledochal web which was treated by balloon dilatation.15 Gulliver et al. described common bile stones to be associated with the web in a significant number of patients.5 Our patient did not, however, have bile duct stones, but clearly had a web present in the CBD and had significant improvement in clinical and biochemical parameters post endoscopic treatment.
Embryologically, the bile ducts in the developing phase become obliterated by epithelial concrescence or proliferation. Later these solid structures become vacuolated, leading to formation of a lumen. Recanalization of the lumen of the biliary tree usually starts at the end of the fifth week of gestation.1 Congenital CBD webs develop due to incomplete re-canalization of this solid structures.2
Introduction: Congenital common bile duct (CBD) webs are extremely rare abnormalities of the extra hepatic ducts with approximately 10 cases reported in the literature. The age at presentation and the clinical symptomatology of these anomalies depend on the grade of the biliary obstruction. These webs usually exhibit early in life as obstructive jaundice, dilation of the proximal biliary tree or even spontaneous perforation of the extra hepatic duct. Some of these congenital webs are partially developed and remain asymptomatic until adulthood.
Goals: A systematic review of studies on patients with dilated CBD was performed to identify etiologies and clinical factors that may predict which patients require further diagnostic testing and long-term outcomes. A PubMed search for relevant articles published between 2001 and 2014 was performed.
Results: The search yielded a total of 882 articles, and after careful individual review for eligibility and relevancy, 9 peer-reviewed studies were included. A cause of the CBD dilation was found on average in 33% of cases and the most common causes were: CBD stone, chronic pancreatitis, and periampullary diverticulum. The overall CBD diameter was not associated with finding a causative lesion. Coexisting CBD and intrahepatic bile duct dilation, age, and jaundice were found to be indicators of pathologic lesions. Dilation of both the CBD and pancreatic duct was suggestive of pancreatic disease, especially pancreatic malignancy in the setting of obstructive jaundice. Follow-up was reported in 6 studies ranging from 6 to 85 months, and generally there was no change in the diagnosis.
Background: With the widespread use of abdominal imaging, an incidentally found dilated common bile duct (CBD) is a common radiographic finding. The significance of a dilated CBD as a predictor of underlying disease and long-term outcome have not been well elucidated.
Conclusions: Incidentally found biliary tract dilatation can be a manifestation of significant biliary tract disease including malignancy. Long-term outcome is not well defined and further prospective studies examining the most cost-effective approach to evaluation are needed.