Double Duct Sign Research Articles

Double duct sign

Double duct sign is an anatomical sign of combined dilatation of common bile duct and pancreatic duct. It is observed on imaging during endoscopic retrograde cholangio-pancreatography, magnetic resonance cholangio-pancreatography, computed tomography and ultrasound. The sign in a jaundiced patient is highly diagnostic of pancreatic carcinoma.

An Octogenarian With Acute Epigastric Pain: More Than Meets the Eye

Question: An 84-year-old woman with a history of dementia and gastroesophageal reflux disease presented to the emergency department with several hours of worsening chest and epigastric pain associated with nausea and vomiting. Upon arrival she was hypertensive to 218/110 mm Hg and had a low-grade fever of 37.8 C. Physical examination was remarkable for epigastric tenderness in a cachectic, elderly woman with mild cognitive impairment. Electrocardiogram and cardiac enzymes ruled out acute coronary syndrome. Further evaluation revealed leukocytosis to 16.1 10/L and markedly abnormal serum liver tests with aspartate aminotransferase of 632 U/L, alanine aminotransferase of 548 U/L, alkaline phosphatase of 309 U/L, and total of bilirubin 1.9 mg/dL. Lipase was at the upper limit of normal. A chest radiograph showed a diaphragmatic hernia without evidence of free air (Figure A). Abdominal ultrasonography showed multiple small choleliths (without signs of acute cholecystitis) and mildly dilated extrahepatic and intrahepatic bile ducts. Cross-sectional imaging was subsequently obtained (Figure B and C) and demonstrated a “double-duct sign” (Figure C), a large diaphragmatic hernia, and an additional critical finding. Based on this patient’s symptoms, serum biochemical tests, and imaging findings, what is the likely etiology of her acute clinical presentation? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Systemic Amyloidosis Presenting as an Ampullary Mass With the Double Duct Sign

Systemic Amyloidosis Presenting as an Ampullary Mass With the Double Duct Sign

In the Groove: A Case Series of Groove Pancreatitis

Background: Groove pancreatitis is an uncommon and under-recognized form of focal chronic pancreatitis of the “sliding plane” between the pancreatic head and duodenum due to obstruction of pancreatic juice flow through the minor duct. This process creates clinical, radiographic, and gross pathologic features that can mimic pancreatic adenocarcinoma. Presentation: We present a series of three male patients ultimately diagnosed with groove pancreatitis. Case 1: A 45 year-old smoker with a history of chronic alcohol ingestion and multiple prior admissions for acute pancreatitis with pancreatic pseudocysts and changes of chronic pancreatitis on imaging. On his seventh admission for pancreatitis, CT scan demonstrated a “double duct sign,” signs of gastric outlet obstruction (GOO), and duodenal thickening which an endoscope was unable to traverse. He subsequently went for pancreaticoduodenectomy and pathology demonstrated chronic pancreatitis, Brunner gland hyperplasia, and no evidence of malignancy. Case 2: A 56 year-old former smoker with severe vascular disease presented with generalized weakness and melena. A CT scan revealed a prominent pancreatic head and a hypodense duodenal mass. Symptomatic GOO lead to pancreaticoduodenectomy and pathology revealed extensive scaring of the pancreatic head and duodenal musculature with numerous cysts, some of which had ruptured suggesting duct malformation. Case 3: A 66 year-old former smoker presented with one year of intermittent bloating, post-prandial abdominal pain, early satiety, nausea, vomiting, and a 20 pound weight loss. Imaging revealed GOO from a duodenal mass and a cystic lesion in the pancreatic head. Endoscopy revealed a large circumferential polypoid mass in the duodenal bulb. Biopsy of this revealed prominent Brunner glands without malignancy. He was treated with gastrojejunostomy leaving the inflammatory mass behind. To date his symptoms have improved and all repeat biopsies were negative for malignancy. Discussion: This case series exemplifies the risk factors and classical findings of groove pancreatitis such as smoking history, duodenal stenosis, “pseudotumor” appearance of the periduodenal space, and Brunner gland hypertrophy. The variations in presentation as demonstrated above can lead to an intricate and diagnostically challenging work-up to rule out malignancy. We also highlight a patient successfully treated without surgical removal of the affected pancreas and duodenum.

Double-Duct Sign in the Clinical Context.

Double-duct sign (combined dilatation of the common bile duct and pancreatic duct) is an infrequently encountered finding in cross-sectional radiological imaging of the pancreatobiliary system. This sign is commonly deemed to signify on ominous pathology and suggests the presence of pancreatic or biliary malignancy. We aim to correlate double-duct sign discovered on magnetic resonance cholangiopancreatogram (MRCP) in the clinical context. We retrospectively analyzed MRCP database over a period of 4 years, January 2010 to December 2013. Follow-up information was available for a median of 27 months (range, 12-42 months) The commonest cause of double-duct sign was choledocholithiasis followed closely by pancreatobiliary malignancy. Patients with jaundice in the context of double-duct sign had a higher incidence of malignancy (48%). None of the anicteric patients were found to have malignancy (P = 0.002). In patients with MRCP evidence of double-duct sign, the absence of jaundice makes a malignant etiology unlikely. Conversely, in jaundiced patients, a malignant cause is much more likely. Figures from larger series are needed to support this conclusion.

Are a Double Duct Sign or Endoscopic Biopsies Reliable Predictors of Malignancy in Periampullary Lesions

Aim: To determine the predictive value of a double duct sign (DDS) and endoscopic biopsies to differentiate invasive carcinoma from premalignant lesions. Methods: Two hundred and forty one patients (mean age 65.8; male 55.6%) diagnosed with a periampullary lesion from January 1987 through March 2013 were reviewed retrospectively with regard to background characteristics, histology of endoscopic biopsy, diameter of both common bile duct (CBD) and main pancreatic duct (PD), bilirubin levels and final diagnosis. Results: DDS predicted malignancy with 73% specificity and 72% sensitivity. Endoscopic biopsies predicted malignancy with 96% specificity, 71% sensitivity and a negative predictive value (NPV) of 51%. Multivariable logistic regression analysis showed that DDS is a significant predictor for the presence of malignancy with an odds ratio of 6.37 adjusted to age, gender and endoscopic biopsy. Conclusion: Although DDS is indicative of malignancy in periampullary lesions, its clinical use is limited, given the low sensitivity and specificity. The diagnostic value of endoscopic biopsies is also poor due to a low sensitivity and NPV. If a double duct sign is present, physicians must be aware of an increased possibility of a malignant underlying cause, even if the histopathological examination of the biopsies did not show invasive malignancy.

Autoimmune pancreatitis in a child presenting as a pancreatic mass

In childhood and adolescence, pancreatic neoplasms are generally treated by resection, whereas the management of pancreatitis is predominantly nonoperative. Autoimmune pancreatitis (AIP) is a form of chronic pancreatitis that frequently presents as a mass and responds to corticosteroids. When serologic tests are not diagnostic, a biopsy may spare a child a pancreatic resection. We report the case of a child who presented with a 3 cm mass in the head of the pancreas with a double duct sign who had AIP. • Diagnostic features of autoimmune pancreatitis differ in children from adults. • Autoimmune pancreatitis can present as a mass and mimic a tumor. • Biopsy may be needed to avoid resection if laboratory tests are inconclusive. • Some cases of idiopathic pancreatitis may be autoimmune pancreatitis. • Resolution of the mass will occur with steroids.

Ominous Yet Benign Double Duct Sign in a Patient on Long-term Methadone Maintenance

Ominous Yet Benign Double Duct Sign in a Patient on Long-term Methadone Maintenance

An unusual cause of simultaneous common bile and pancreatic duct dilation.

Simultaneous dilation of both the common bile duct and the pancreatic duct (double-duct sign) is usually because of ampullary or pancreatic tumours. Here we report an unusual cause of double-duct dilation; we describe the case of a 49-year-old female who developed afferent loop syndrome after pylorus-preserving pancreaticoduodenectomy: cross-sectional imaging of the abdomen revealed a double-duct sign.

PTH-014 Pancreatic Duct Dilatation Should Be Investigated With Endoscopic Ultrasound If Computerised Tomography Fails To Identify A Lesion

IntroductionA dilated Pancreatic Duct (PD) may be associated with pancreatic disease, but this is infrequently investigated further if no lesion is found on Computerised Tomography (CT). There is limited data...

PTH-105 How Ominous Is The “double-duct” Sign ?: A Single Centre Experience

Introduction“Double-duct” sign on ERCP (Endoscopic retrograde cholangio-pancreatogram) is considered suggestive of pancreatic or biliary malignancy. This sign is frequently encountered in radiological imaging. We wish to investigate the prognostic value...

Preoperative characteristics of patients with presumed pancreatic cancer but ultimately benign disease: a multicenter series of 344 pancreatoduodenectomies.

Preoperative differentiation between malignant and benign pancreatic tumors can be difficult. Consequently, a proportion of patients undergoing pancreatoduodenectomy for suspected malignancy will ultimately have benign disease. The aim of this study was to compare preoperative clinical and diagnostic characteristics of patients with unexpected benign disease after pancreatoduodenectomy with those of patients with confirmed (pre)malignant disease. We performed a multicenter retrospective cohort study in 1,629 consecutive patients undergoing pancreatoduodenectomy for suspected malignancy between 2003 and 2010 in 11 Dutch centers. Preoperative characteristics were compared in a benign:malignant ratio of 1:3. Malignant cases were selected from the entire cohort by using a random number list. A multivariable logistic regression prediction model was constructed to predict benign disease. Of 107 patients (6.6%) with unexpected benign disease after pancreatoduodenectomy, 86 fulfilled the inclusion criteria and were compared with 258 patients with (pre)malignant disease. Patients with benign disease presented more often with pain (56 vs. 38%; P=0.004), but less frequently with jaundice (60 vs. 80%; P<0.01), a pancreatic mass (13 vs. 54%, P<0.001), or a double duct sign on computed tomography (21 vs. 47%; P<0.001). In a prediction model using these parameters, only 19% of patients with benign disease were correctly predicted, and 1.4% of patients with malignant disease were missed. Nearly 7% of patients undergoing pancreatoduodenectomy for suspected malignancy were ultimately diagnosed with benign disease. Although some preoperative clinical and imaging characteristics might indicate absence of malignancy, their discriminatory value is insufficient for clinical use.

Mo1489 Endoscopic Ultrasound Evaluation of Double Duct Sign: a Tertiary Referral Centre Experience

Computer Tomography (CT) and Magnetic Resonance Imaging (MRI) scanners are used to evaluate patients with ‘double duct sign' (Dilated common bile duct (CBD) and pancreatic ducts). Often no abnormality is detected on imaging and patients are subsequently investigated with Endoscopic Ultrasound (EUS).

Double-Duct Sign in the Era of Endoscopic Ultrasound: The Prevalence of Occult Pancreaticobiliary Malignancy

Simultaneous dilatation of the common bile duct and pancreatic duct, "double-duct sign" (DDS), is an ominous finding concerning for pancreaticobiliary malignancy. Little evidence exists to guide the initial evaluation and subsequent follow-up for patients with DDS in the absence of jaundice or focal mass noted on computed tomography (CT)/ magnetic resonance imaging (MRI). Endoscopic ultrasound (EUS) is often recommended in the evaluation of such patients, however, the prevalence of malignancy remains unclear. We sought to determine the prevalence of pancreaticobiliary neoplasm in this patient group on initial EUS evaluation and on subsequent clinical follow-up. We performed a retrospective analysis of a prospective database at a tertiary-care academic medical center between 2010 and 2012. Eighty-two patients were identified who underwent EUS evaluation for DDS without evidence of a mass on CT/MRI and without jaundice. Sixty-eight of 82 patients had confirmed DDS on EUS with biductal dilation. Six (9 %) of 68 patients were found to have a mass lesion on EUS. In these patients, final diagnoses were pancreatic carcinoma (n = 4), ampullary carcinoma (n = 1) and ampullary adenoma (n = 1). In the 62 patients without evidence of a focal mass on initial EUS, the most common diagnoses were benign ductal dilation (n = 42), chronic pancreatitis (n = 9) and choledocholithiasis (n = 8). Fifty-eight (94 %) of 62 patients had documented median follow-up of 13 months, and none developed subsequent evidence of previously unrecognized malignancy. The presence of double-duct sign on EUS in patients without jaundice or mass lesion on CT/MRI is most frequently associated with benign conditions. When a mass is not detected on EUS, subsequent evidence of malignancy is unlikely.

Simultaneous Courvoisier�s and Double Duct Signs

Presence of Courvoisier’s or double duct signs in a jaundiced patient is suggestive of malignant obstruction of the pancreaticobiliary ductal system however; the oncologic significance of the simultaneous occurrence of these signs is unknown. We report a case of obstructive jaundice secondary to a periampullary tumor demonstrating the Courvoisier’s sign on clinical examination and a double duct sign on imaging who underwent a Whipple operation which confirmed an ampullary adenocarcinoma.

Now You See It, Now You Don't: An Unusual Cause of the “Double Duct Sign”

Now You See It, Now You Don't: An Unusual Cause of the “Double Duct Sign”

Double Duct Sign in a 3-Year-Old Child

Question: A 3-year-old boy from a family of low socioeconomic status living in a tropical country presented with complaint of upper abdominal pain, high-grade fever, and jaundice. Laboratory investigations revealed: hemoglobin, 10.6 gm%; total leukocyte count, 13,800; differential leukocyte count, P86; lymphocyte, 14; erythrocyte sedimentation rate, 36; alanine aminotransferase, 374 U/L (normal, 0–50); aspartate aminotransferase, 356 U/L (normal, 5–50); serum alkaline phosphatase, 768 U/L (normal, 25–125); and serum bilirubin, 5.1 mg/dL (normal, 0.2–1.1); serum amylase, 700 U/L (normal, 20–80); and serum lipase, 500 U/L (normal, 0–190).

Use of Diffusion-Weighted MRI to Differentiate Chronic Pancreatitis From Pancreatic Cancer

The purpose of this study was to compare diffusion-weighted MRI (DWI) and conventional (non-DWI) MRI sequences in differentiating mass-forming chronic pancreatitis from pancreatic cancer. A retrospective cohort study included 36 patients who underwent pancreatic resection for pancreatic cancer (n = 13) and chronic pancreatitis (n = 23) after preoperative MRI with DWI. Two independent reviewers assessed the DW images for signal intensity and apparent diffusion coefficient (ADC) values. Four weeks later, they reviewed the other MR images for size of mass, double-duct sign, pancreatic duct cutoff, and perivascular soft-tissue cuffing. A score for conventional MRI was given with 1 meaning definitely benign and 5 meaning definitely malignant. Univariate and multivariate analyses and receiver operating characteristic (ROC) curve analysis were performed with surgical pathologic examination as the reference standard. The only finding that differentiated the two groups was the presence of a well-defined mass, favoring the diagnosis of cancer (p = 0.02, p < 0.01). There was no significant difference between the two groups in signal intensity on DW images (p = 0.82, p = 0.85) or ADC (p = 0.51, p = 0.76). Double-duct sign, pancreatic duct cutoff, and perivascular soft-tissue cuffing were not useful in differentiating the two groups. The areas under the ROC curve were 0.873 and 0.878 for the conventional MRI scores, compared with 0.602 and 0.552 for ADC measurements (p = 0.02, p = 0.008). The addition of DWI to conventional MRI does not facilitate differentiation of pancreatic cancer from chronic pancreatitis.

Type 1 Sphincter of Oddi Dysfunction due to Chronic Opium Addiction

Although the presence of a dilated common bile duct and pancreatic duct, known as ‘double duct sign,’ suggests underlying malignancy, the differential diagnosis does include some benign causes. Endoscopic ultrasound can be useful for differentiation of malignancy from type 1 sphincter of Oddi dysfunction (SOD). Herein are demonstrated the characteristic endosonographic features of type 1 SOD in two patients with chronic opium abuse. This article is part of an expert video encyclopedia.

Pancreatic Carcinoma Stage T3N1

The double-duct sign, a simultaneous stenosis of the common bile duct and the pancreatic duct, is suggestive of the presence of a pancreatic cancer. Here the configuration by imaging with both endoscopic retrograde cholangiopancreatography and endosonography, in a case with pancreatic head carcinoma is demonstrated. This article is part of an expert video encyclopedia.