ECTOPIC OPENING OF THE COMMON BILE DUCT INTO THE PYLORIC CHANNEL

Abstract

Ectopic opening of the common bile duct is extremely rare. There are scant reports in the literature describing ectopic bile duct insertion, and the clinical implication of this finding is unclear. We describe a case of the common bile duct (CBD) opening into the pyloric channel. A previously healthy 47-year-old male presented with a 3 day history of right upper quadrant abdominal pain, fever, nausea and vomiting. On examination, he was febrile to 104°F, icteric, and tender to palpation of the right upper quadrant. Labs revealed leukocytosis with a left shift (WBC 11,100 and 93% PMN) and cholestasis with mild transaminitis (total bilirubin 4.9, direct bilirubin 2.7, alkaline phosphatase 211, ALT 140 and AST 212). Imaging showed mild CBD dilatation and gallstones within a gallbladder that had wall thickening and pericholecystic fluid. The patient was resuscitated with IV fluids and antibiotics with some improvement. The patient underwent ERCP for suspected choledocholithiasis and possible cholangitis. No papilla could be found after extensive examination of the duodenal wall during ERCP. The duodenoscope was withdrawn and a front-viewing endoscope was inserted. A small slit-like opening of the CBD was identified within the pyloric channel. The opening was cannulated using a standard catheter. Cholangiogram confirmed it was the CBD and revealed several small filling defects within a normal appearing CBD. While most of the filling defects were thought to be air bubbles, small stones cannot be ruled out. Due to the location of the opening, sphincterotomy cannot be performed and a biliary stent was inserted for drainage. The pancreatic duct could not be cannulated, and no separate opening for the pancreatic duct was found. The patient's symptoms subsequently resolved and he was later taken for cholecystectomy. Our case demonstrates an opening of the CBD into the pyloric channel. Other sites of bile duct insertion that have been described include the stomach, duodenal bulb, third and fourth portions of the duodenum. Clinical implications of these anomalous sites of insertion are not known. Some authors suggest these openings are at higher risk for biliary disease based on altered duct anatomy and lack of sphincter of Oddi function. In addition, when biliary disease occurs it may be more difficult to treat due to altered anatomy.