Anomalous Pancreaticobiliary Junction Research Articles

An Unusual Variant of Anomalous Pancreaticobiliary Junction.

A 27-year-old previously healthy African American female presented to the Emergency Department with an acute onset of epigastric abdominal pain and nausea. Laboratory studies proved unremarkable. CT scan demonstrated intrahepatic and extrahepatic biliary ductal dilation with possible stones within the common bile duct. The patient was discharged with a surgery follow-up appointment. Laparoscopic cholecystectomy with intraoperative cholangiography was performed 3weeks later due to concern for choledocholithiasis. The intraoperative cholangiogram showed multiple abnormalities, concerning for an infectious or inflammatory process. Magnetic resonance cholangiopancreatography (MRCP) demonstrated a suspected anomalous pancreaticobiliary junction and cystic lesion near the pancreatic head. Endoscopic retrograde cholangiopancreatography (ERCP) for cholangioscopy showed normal-appearing pancreaticobiliary mucosa with 3 tributaries directly from the pancreas entering the bile duct and an ansa orientation to the pancreatic duct. Biopsies of the mucosa were benign. Annual MRCP and MRI to assess for findings concerning for neoplasm given the anomalous pancreaticobiliary junction were recommended.

Diagnostic challenge: Mirizzi syndrome with anomalous pancreaticobiliary junction.

Diagnostic challenge: Mirizzi syndrome with anomalous pancreaticobiliary junction.

S1659 A Case of Gallbladder Agenesis and Anomalous Pancreaticobiliary Junction With Chronic Choledocholithiasis and Secondary Biliary Cirrhosis

S1659 A Case of Gallbladder Agenesis and Anomalous Pancreaticobiliary Junction With Chronic Choledocholithiasis and Secondary Biliary Cirrhosis

S1616 Primary Carcinosarcoma of the Gallbladder: An Unfortunate Fate From Anomalous Pancreaticobiliary Junction

S1616 Primary Carcinosarcoma of the Gallbladder: An Unfortunate Fate From Anomalous Pancreaticobiliary Junction

Nadir Bir Konjenital Safra Anomalisi: Pankreatikobiliyer Bilişim Anomalisi

20-year-old female patient was admitted with complaints of girdle-like abdominal pain, nausea and vomiting. A history of pancreatitis 2 years ago was found in the patient’s anamnesis. Physical examination showed tenderness in the epigastric region, other system examinations were normal. In laboratory tests, amylase was found as 1249 ıu/l, lipase was found as 1068 u/l, CRP (C-Reaktif Protein) was found as 49.83mg/l and they were found to be high. Liver function tests, kidney function tests and electrolytes were found to be normal. In the abdomen ultrasonography, pancreas was reported to have increased size and mild edema. The patient was hospitalized with these findings and intravenous fluid replacement was started. Magnetic resonance cholangiopancreatography (MRCP) was performed on the patient whose vital findings were stable. MRCP showed that common bile duct and pancreatic duct were joined at 17 mm proximal from the normal anatomic location. Anomalous pancreaticobiliary junction (APBJ) is a rare congenital anomaly and in recent years its diagnosis frequency has increased due to the widespread use of advanced radiological examinations such as MRCP. The purpose of this case presentation was to present the APBJ that we detected with MRCP in a patient with recurrent pancreatitis attacks.

Secretin-Enhanced MRCP: How and Why-AJR Expert Panel Narrative Review.

Secretin-enhanced MRCP (S-MRCP) has advantages over standard MRCP for imaging of the pancreaticobiliary tree. Through the use of secretin to induce fluid production from the pancreas and leveraging of fluid-sensitive MRCP sequences, S-MRCP facilitates visualization of ductal anatomy, and the findings provide insight into pancreatic function, allowing radiologists to provide additional insight into a range of pancreatic conditions. This narrative review provides detailed information on the practical implementation of S-MRCP, including patient preparation, logistics of secretin administration, and dynamic secretin-enhanced MRCP acquisition. Also discussed are radiologists' interpretation and reporting of S-MRCP examinations, including assessments of dynamic compliance of the main pancreatic duct and of duodenal fluid volume. Established indications for S-MRCP include pancreas divisum, anomalous pancreaticobiliary junction, Santorinicele, Wirsungocele, chronic pancreatitis, main pancreatic duct stenosis, and assessment of complex postoperative anatomy. Equivocal or controversial indications are also described along with an approach to such indications. These indications include acute and recurrent acute pancreatitis, pancreatic exocrine function, sphincter of Oddi dysfunction, and pancreatic neoplasms.

Causes and Countermeasures of Difficult Selective Biliary Cannulation: A Large Sample Size Retrospective Study.

Selective biliary cannulation is a difficult part of endoscopic retrograde cholangiopancreatography (ERCP). Therefore, endoscopists have focused on how to improve the cannulation success rate and reduce the postoperative complication rate. This study aims to provide practical advice on safe operation for endoscopists. Data from the ERCP database of our medical center from January 2008 to December 2017 were retrospectively reviewed. All patients underwent ERCP for the first time. Data pertaining to diseases, anatomic factors, difficult cannulation rates, cannulation success rates, and postoperative complication rates for various assistive cannulation techniques were analyzed by using the Pearson χ2 tests and Fisher exact tests. The difficult cannulation rate was 8.1%. The main influencing factors were benign and malignant biliary stricture, duodenal papillae or ampullary tumors, thick and long duodenal papillae, peridiverticular papillae, ectopic papillae, edematous papillae, ulcerative papillae, anomalous pancreaticobiliary junction, and Billroth II gastrectomy. The postoperative complication rates and overall cannulation success rates of 7 assistive techniques were not statistically different (P>0.05), but the overall complication rates were statistically different (P<0.05). Needle-knife precut sphincterotomy had the highest rate of complications. Benign and malignant biliary stricture, duodenal papillae or ampullary tumors, thick and long duodenal papillae, peridiverticular papillae, ectopic papillae, edematous papillae, ulcerative papillae, anomalous pancreaticobiliary junction, and Billroth II gastrectomy were the main factors of difficult selective biliary cannulation. The overall incidence of needle-knife precut sphincterotomy complications was higher than that of other techniques, but various assistive techniques were safe and effective in our single center.

S0117 Risk of Gallbladder Cancer With Increasing Gallstone Size: A Systematic Review and Meta-Analysis

INTRODUCTION: Gallbladder (GB) cancer (GBC) accounted for 3960 deaths in the US in 2019. With only 1 in 5 GBCs diagnosed at early stage, the overall 5-year survival rate is a meager 19%. Given the low 5-year survival, the best treatment is prevention. Risk factors for GBC include age, ethnicity, GB polyps >1 cm, primary sclerosing cholangitis, anomalous pancreaticobiliary junction, toxins, and GB stones. There remains controversy as to whether size of GB stones increases the risk of GBC. The aim of this systematic review and meta-analysis was to determine if risk of GBC increases with increasing size of GB stones. METHODS: A systematic search was conducted using the terms “gallbladder cancer,” “cholelithiasis,” “gallstones,” and “gallstone size” with all permutations of pubmed/medline, google scholar, embase, and cochrane. Papers were translated, if necessary. A recursive search of bibliographies of included articles was also performed. GB stone size was primarily determined post-cholecystectomy. The relevant data was inputted into RevMan 5.4 in order to generate odds ratios and Forest plots. RESULTS: The search yielded 357 total articles, of which 8 met our final inclusion criteria with GB stone measurement and prevalence of GBC in each study population. The data was then divided into 3 groups, based on size of GB stones, greater or lesser than 3 cm, 2 cm, or 1 cm. We found that the OR of developing GBC was 1.93 [1.29–2.90], 1.42 [1.06–1.90], and 1.62 [1.24–2.11] for stones greater than 3 cm, 2 cm, and 1 cm, respectively. CONCLUSION: Patients with GB stones >1 cm had increased odds of developing GBC, however we did not observe a linear relationship between GBC and increasing stone size. Our meta-analysis found an OR of 1.93 for stones >3 cm which is significantly less than the 9.1 previously reported. The association between GB stone size and GBC is likely related to the chronicity of GB stones rather than absolute size. Jain et al. proposed that chronic inflammation could subsequently lead to loss of heterozygosity of tumor suppressor genes. In summary, we found the risk of GBC is similar regardless of size of stones >1 cm. Therefore while we usually observe asymptomatic GB stones, clinicians should be aware that GB stones >1 cm may have increased risk of GBC in symptomatic individuals. Further studies are needed in asymptomatic individuals to define the optimal GB stone size cutoff to perform cholecystectomy to reduce GBC risk.Figure 1.: Odds of developing gallbladder cancer with increasing size of gallstones. (Events = # of cases of gallbladder cancer; Total = # of cases of patients with gallstones > or < the specified size).

Choledochal cysts: Similarities and differences between Asian and Western countries.

Choledochal cysts (CCs) are rare bile duct dilatations, intra-and/or extrahepatic, and have higher prevalence in the Asian population compared to Western populations. Most of the current literature on CC disease originates from Asia where these entities are most prevalent. They are thought to arise from an anomalous pancreaticobiliary junction, which are congenital anomalies between pancreatic and bile ducts. Some similarities in presentation between Eastern and Western patients exist such as female predominance, however, contemporary studies suggest that Asian patients may be more symptomatic on presentation. Even though CC disease presents with an increased malignant risk reported to be more than 10% after the second decade of life in Asian patients, this risk may be overstated in Western populations. Despite this difference in cancer risk, management guidelines for all patients with CC are based predominantly on observations reported from Asia where it is recommended that all CCs should be excised out of concern for the presence or development of biliary tract cancer.

Intracholecystic papillary-tubular neoplasm in a patient with choledochal cyst and anomalous pancreaticobiliary junction: case report

A 75-year-old female incidentally presented with an enhancing intraluminal gallbladder mass, main bile duct dilatation and anomalous pancreaticobiliary junction (APBJ) during the staging of gastric adenocarcinoma. Histopathological analysis confirmed the diagnosis of intracholecystic papillary-tubular neoplasm. Intracholecystic papillary-tubular neoplasms (ICPN) of the gallbladder are rare gallbladder neoplasms, defined as intramucosal, preinvasive, exophytic, mass forming lesions. An association between choledochal cysts and anomalous pancreaticobiliary junction with gallbladder neoplasms is well known, and this case potentially illustrates gallbladder carcinogenesis related to these biliary anomalies.

AB059. P-28. Is cholangiocarcinoma the only concern in western adult patients with choledochal cyst (CC) disease and anomalous pancreaticobiliary junction (APBJ)?

AB059. P-28. Is cholangiocarcinoma the only concern in western adult patients with choledochal cyst (CC) disease and anomalous pancreaticobiliary junction (APBJ)?

Endoscopic dissection of refractory pancreatic duct stricture via accessory pancreatic duct approach for concurrent treatment of anomalous pancreaticobiliary junction in aging patients.

BackgroundAlthough endoscopic management of pancreatic strictures by dilation and stenting is well established, some high-grade strictures are refractory to conventional methods. Here, we report a novel technique via accessory pancreatic duct (APD) approach to simultaneously release chronic pancreatitis-associated pancreatic stricture and correct anomalous pancreaticobiliary junction (APBJ). Due to APBJ and stricture of proximal main pancreatic duct, the APD turned out to be compensatory expansion. The stiff stenosis was dissected along the axial of APD using needle-knife electrocautery or holmium laser ablation, and then the supporting stent was placed into the pancreatic body duct. By doing so, the outflow channels of pancreatic and biliary ducts were exquisitely separated.Patients and methodsTwo patients aged 69 and 71 years underwent stricture dissection and stent insertion for fluent drainage of pancreatic juice. The postoperative course was marked by complete abdominal pain relief and normal blood amylase recovery. In the first patient, wire-guided needle-knife electrocautery under fluoroscopic control was applied to release refractory stricture. The second patient was treated by SpyGlass pancreatoscopy-guided holmium laser ablation to lift pancreatic stricture.ResultsPlastic stents in APD were removed at 3 months after surgery, and magnetic resonance imaging at 6 months showed strictly normal aspect of the pancreatic duct.ConclusionAlthough both cases were successful without severe complications, we recommend this approach only for selected patients with short refractory pancreatic strictures due to chronic pancreatitis. In order to prevent severe complications (bleeding, perforation or pancreatitis), direct-view endoscopy-guided electrotomy needs to be developed.

Choledochal cysts and anomalous pancreaticobiliary junction in a western population: a tertiary care, single center experience

Choledochal cysts and anomalous pancreaticobiliary junction in a western population: a tertiary care, single center experience

Coexistence of Complete Pancreas Divisum and Anomalous Pancreaticobiliary Junction in a Patient With Type IA Choledochal Cyst

Coexistence of Complete Pancreas Divisum and Anomalous Pancreaticobiliary Junction in a Patient With Type IA Choledochal Cyst

Symptomatic benign distal biliary stricture in the setting of anomalous pancreaticobiliary junction treated with metal biliary and temporary plastic pancreatic stents

Symptomatic benign distal biliary stricture in the setting of anomalous pancreaticobiliary junction treated with metal biliary and temporary plastic pancreatic stents

An Unusual Case of Choledochal Cyst, Anomalous Pancreaticobiliary Junction and Incomplete Pancreas Divisum

An Unusual Case of Choledochal Cyst, Anomalous Pancreaticobiliary Junction and Incomplete Pancreas Divisum

Prospective evaluation of yield of endoscopic ultrasonography in the etiological diagnosis of "idiopathic" acute pancreatitis

Abstract Background: Etiology of acute pancreatitis (AP) remains idiopathic in 30% of patients. Endoscopic ultrasound (EUS) has been shown to increase the diagnostic yield in patients with idiopathic AP (IAP). Aim: The aim of this study was to evaluate the role of EUS in achieving etiological diagnosis in patients with IAP. Materials and Methods: Consecutive 192 patients with IAP were evaluated prospectively with EUS over a period of 2 years. Patients who had no etiological diagnosis for AP after detailed history, clinical examination, laboratory investigations, and magnetic resonance cholangiopancreatography were included in the study. Results: The mean age of patients was 34.6 ± 12 and male:female ratio was 2.1:1. Of these, 135 patients had gallbladder intact (Group A) and 57 patients had undergone cholecystectomy (Group B). In Group A, EUS identified a possible cause in 79 (58.5%) patients; microlithiasis (n = 48), chronic pancreatitis (CP) (n = 23), common bile duct (CBD) and gallbladder stone (n = 3), pancreatic divisum (n = 3), small pancreatic tumor (n = 1), and anomalous pancreaticobiliary junction (n = 1). In Group B, EUS yielded diagnosis in 28 (49.1%) patients; CP (n = 22), ascariasis (n = 3), CBD stone (n = 2), and pancreatic divisum (n = 1). Overall EUS helped in achieving etiological diagnosis in 107 (55.1%) of patients with IAP. The presence of intact gallbladder showed a tendency for increased diagnostic yield (P = 0.06). Conclusion: EUS is a useful modality to establish the diagnosis in IAP and this technique should be incorporated in the evaluation of IAP.

Role of ERCP in Patients With Idiopathic Recurrent Acute Pancreatitis.

Recurrent acute pancreatitis (RAP) is defined based on the occurrence of two or more episodes of acute pancreatitis. RAP is differentiated from chronic pancreatitis based on the presence of a normal morphological appearance of the pancreas between episodes. RAP can be due to a variety of etiologies including common bile duct stones or sludge, sphincter of Oddi dysfunction (SOD), pancreas divisum (PD), anomalous pancreaticobiliary junction, genetic mutations, and alcohol related. In approximately 30% of patients, the etiology of RAP is unclear and the term "idiopathic" is used. Endoscopic retrograde cholangiopancreatography (ERCP) can be utilized in both the diagnosis and the initial management of RAP, but it has known limitations and risks. Since gallbladder sludge and SOD account for most cases with RAP, cholecystectomy and, eventually, endoscopic biliary and/or pancreatic sphincterotomy are performed as a part of management. In patients with PD-associated RAP, data from uncontrolled and primarily retrospective studies point toward a benefit from minor papillary endoscopic intervention. However, given the lack of quality data from prospective randomized controlled trials (RCTs), endoscopic management in such patients remains an individualized decision, and RCTs are needed to ascertain its true long-term benefit. Future studies to investigate the role of endoscopic therapy in preventing progression to chronic pancreatitis are needed.

Sphincter of Oddi Dysfunction and the Formation of Adult Choledochal Cyst Following Cholecystectomy: A Retrospective Cohort Study.

To determine the causes underlying the formation of adult choledochal cyst.Anomalous pancreaticobiliary junction is the most widely accepted theory regarding the etiology of choledochal cyst. However, choledochal cysts have been found in patients in the absence of this anomaly. Because the number of adult patients with choledochal cyst is increasing, it is important to address this controversy.Bile amylase levels in the cysts of 27 patients (8 males and 19 females) who had undergone cholecystectomy were retrospectively evaluated.The average age of the 27 patients was 45.8 ± 10.1 years and the majority (85.2%) were diagnosed with Todani type I cysts. None of the patients had dilatation of the common bile duct prior to surgery. There were 6 (22.2%) patients with anomalous pancreaticobiliary junction. However, amylase levels did not significantly differ between patients with and without this anomaly (P = 0.251). According to bile amylase levels, pancreatobiliary reflux was present in 21 (77.8%) patients. The mean amylase level significantly differed in patients with pancreatobiliary reflux (23,462 ± 11,510 IU/L) and those without (235 ± 103 IU/L) (P < 0.001). In patients with pancreatobiliary reflux, only 4 patients had anomalous pancreaticobiliary junction. That is, the majority of patients (17/21, 81%) having pancreatobiliary reflux did not have an anomalous junction of the pancreatic and biliary ducts.Since the only explanation for pancreatobiliary reflux in patients with a normal pancreaticobiliary junction is sphincter of Oddi dysfunction, we proposed that the formation of adult choledochal cyst is mainly due to sphincter of Oddi dysfunction.

Congenital double bile duct presenting as recurrent cholangitis in a child

Double common bile duct (DCBD) is a rare congenital anomaly. Most of these bile duct anomalies are associated with bile duct stones, anomalous pancreaticobiliary junction (APBJ), pancreatitis and bile duct or gastric cancers. Early detection and treatment is important to avoid long term complications. Surgical resection of the anomalous bile duct and reconstruction of the biliary enteric anastomosis is the treatment of choice. We report a rare case of DCBD anomaly in a girl, who presented with recurrent cholangitis. She had type Va DCBD anomaly. She underwent successful resection of the bile duct and reconstruction of the biliary enteric anastomosis. Preoperative imaging and diagnosis of the congenital biliary anomaly is very important to avoid intraoperative bile duct injury. Review of the literature shows very few cases of type Va DCBD, presenting with either bile duct stones or APBJ.