High Confluence Of Pancreaticobiliary Ducts Research Articles

"Mathematical Investigation for the Mechanism of the Pancreatic Juice Reflux in High Confluence of Pancreaticobiliary Ducts and Pancreaticobiliary Maljunction"

"Mathematical Investigation for the Mechanism of the Pancreatic Juice Reflux in High Confluence of Pancreaticobiliary Ducts and Pancreaticobiliary Maljunction"

Investigation of pancreatic juice reflux mechanism in high confluence of pancreaticobiliary ducts and pancreaticobiliary maljunction (Development and validation of a mathematical model for pancreatic and bile juice flow based on fluid mechanics)

Investigation of pancreatic juice reflux mechanism in high confluence of pancreaticobiliary ducts and pancreaticobiliary maljunction (Development and validation of a mathematical model for pancreatic and bile juice flow based on fluid mechanics)

Elevated bile amylase level without pancreaticobiliary maljunction is a risk factor for gallbladder carcinoma.

Elevated bile amylase level in patients with pancreaticobiliary maljunction (PBM) or high confluence of pancreaticobiliary ducts (HCPBD) is well known as a risk factor for gallbladder carcinoma (GBC) development. However, the effects of occult pancreaticobiliary reflux (OPR), a condition characterized by high bile amylase level in the presence of an anatomically normal pancreaticobiliary junction, on GBC development remain unclear. The aim of this study was to assess the relationship between OPR and GBC. Clinicopathological data of 52 patients who were preoperatively diagnosed with gallbladder (GB) tumor (22 malignant, 30 benign) were retrospectively reviewed. All of the patients underwent preoperative endoscopic retrograde cholangiopancreatography to evaluate pancreaticobiliary junction morphology and bile amylase level. The relationship between the histological diagnosis of GB lesions, and pancreaticobiliary junction morphology and bile amylase level were investigated. Pancreaticobiliary maljunction, HCPBD, and normal pancreaticobiliary junction (NPJ) were identified in 12, nine, and 31 patients, respectively. The rates of GBC in patients with PBM, HCPBD, and NPJ were 58% (7/12), 67% (6/9), and 29% (9/31), respectively. Of the 31 patients with NPJ, 22 had OPR and nine of these had GBC. None of the patients with NPJ and normal bile amylase level had GBC. Additionally, among patients with NPJ, bile amylase level was significantly higher in patients with GBC than in patients with benign tumors. Occult pancreaticobiliary reflux, like PBM and HCPBD, is a risk factor for GBC development.

A Case of High Confluence of Pancreaticobiliary Ducts Which Presented with Acute Cholecystitis

Introduction: High confluence of pancreaticobiliary ducts (HCPBD) is defined as a disease state in which the common channel length is greater than or equal to 6 mm and causes pancreatobiliary or biliopancreatic reflux, but not classified as pancreaticobiliary maljunction (PBM). Case report: A 65-year-old man had an intermittent pain in the right hypochondriac region for 2 weeks. He was diagnosed as acute cholecystitis, and percutaneous transhepatic gallbladder drainage was performed. Amylase level of drained bile from the gallbladder was elevated to 66260 IU/L suggesting of pancreatobiliary reflux. A trans-gallbladder cholangiography revealed a communication between the cystic dilatation of the intraduodenal common bile duct and the pancreatic duct. Endoscopic retrograde cholangiopancreatography (ERCP) could not identify PBM and showed the relatively long common channel with cystic dilatation and the common bile duct (CBD). Pancreatic duct was not shown easily due to the contraction of the sphincter of Oddi in the pancreatobiliary ductal junction. Simultaneous intraductal ultrasonography showed no visible lesions in the CBD. He was diagnosed as having HCPBD. Endoscopic sphincterotomy (EST) was successfully performed to prevent pancreaticobiliary or biliopancreatic reflux which would cause cholecystitis and pancreatitis. After EST, postprandial biliary amylase level in the gallbladder was low (67 IU/L). Later, he underwent laparoscopic cholecystectomy. Although chronic inflammation was observed, there was no cancer tissue in the gallbladder. Until now, he has no recurrence of cholangitis and pancreatitis. Conclusion: EST is a safe and effective treatment for pancreatobiliary or biliopancreatic reflux due to HCPBD. We should remember that HCPBC has a significant risk to develop gallbladder cancer, even though lower than that of PBM. Therefore, it is necessary to follow up patients with HCPBD after EST. The necessity of preventive cholecystectomy is controversial.

Pancreaticobiliary maljunction and biliary cancer.

Pancreaticobiliary maljunction (PBM) is a congenital malformation in which the pancreatic and bile ducts join anatomically outside the duodenal wall. Japanese clinical practice guidelines on how to deal with PBM were made in 2012, representing a world first. According to the 2013 revision to the diagnostic criteria for PBM, in addition to direct cholangiography, diagnosis can be made by magnetic resonance cholangiopancreatography (MRCP), 3-dimensional drip infusion cholangiography computed tomography, endoscopic ultrasonography (US), or multiplanar reconstruction images by multidetector row computed tomography. In PBM, the common channel is so long that sphincter action does not affect the pancreaticobiliary junction, and pancreatic juice frequently refluxes into the biliary tract. Persistence of refluxed pancreatic juice injures epithelium of the biliary tract and promotes cancer development, resulting in higher rates of carcinogenesis in the biliary tract. In a nationwide survey, biliary cancer was detected in 21.6% of adult patients with congenital biliary dilatation (bile duct cancer, 32.1% vs. gallbladder cancer, 62.3%) and in 42.4% of PBM patients without biliary dilatation (bile duct cancer, 7.3% vs. gallbladder cancer, 88.1%). Pathophysiological conditions due to pancreatobiliary reflux occur in patients with high confluence of pancreaticobiliary ducts, a common channel ≥6 mm long, and occlusion of communication during contraction of the sphincter. Once the diagnosis of PBM is established, immediate prophylactic surgery is recommended. However, the surgical strategy for PBM without biliary dilatation remains controversial. To detect PBM without biliary dilatation early, MRCP is recommended for patients showing gallbladder wall thickening on screening US under suspicion of PBM.

Exploring the length of the common channel of pancreaticobiliary maljunction on magnetic resonance cholangiopancreatography.

In the revised diagnostic criteria for pancreaticobiliary maljunction (PBM), PBM can be diagnosed from a long common channel by magnetic resonance cholangiopancreatography (MRCP). However, it is necessary to differentiate from high confluence of pancreaticobiliary ducts (HCPBD) with a relatively long common channel (≥6 mm) and effect of the sphincter in the pancreaticobiliary junction. This multicenter study aimed to explore definite value of the length of an abnormally long common channel, which enables to distinguish PBM from HCPBD on MRCP. In 184 PBM patients and 22 HCPBD patients who were diagnosed by direct cholangiography and underwent MRCP, the length of the common channel was measured. The length of the common channel was 16.2 ± 6.9 mm on direct cholangiography and 13.9 ± 6.2 mm on MRCP in PBM patients, and 7.7 ± 1.5 mm and 6.6 ± 1.4 mm in HCPBD patients. The optimal cut off value of the length of the common channel to distinguish PBM from HCPBD was identified to be 9 mm. Pancreaticobiliary maljunction can be diagnosed from an abnormally long common channel on MRCP, but in cases of the common channel ≤9 mm on MRCP, direct cholangiography is needed to confirm PBM.

Annular pancreas concurrent with pancreaticobiliary maljunction presented with symptoms until adult age: case report with comparative data on pediatric cases

BackgroundAnnular pancreas (AP) concurrent with pancreaticobiliary maljunction (PBMJ), an unusual coexisted congenital anomaly, often presented symptoms and subjected surgical treatment at the early age of life. We reported the first adult case of concurrent AP with PBMJ presented with symptoms until his twenties, and performed a literature review to analyze the clinicopathological features of such cases comparing with its pediatric counterpart.Case presentationThe main clinical features of this case were abdominal pain and increased levels of plasma amylase as well as liver function test. A complete type of annular pancreas with duodenal stenosis was found, and dilated common bile duct with high confluence of pancreaticobiliary ducts was also observed. Meanwhile, extremely high levels of bile amylase were detected both in common bile duct and gallbladder. The patient received duodenojejunostomy (side-to-side anastomosis) as well as choledochojejunostomy (Roux-en-Y anastomosis), adnd was discharged in a good condition.ConclusionAP concurrent with PBMJ usually presents as duodenal obstruction in infancy, while manifests as pancreatitis in adulthood. Careful long-term follow-up is required for children with AP considering its association with PBMJ which would induce various intractable pathologic conditions in the biliary tract and pancreas.

Etiology of recurrent acute pancreatitis, with special emphasis on pancreaticobiliary malformation

This study was aimed to investigate etiology and clinical profiles of recurrent acute pancreatitis (RAP), particularly from the morphology of the pancreaticobiliary duct system. Pancreaticobiliary morphology was examined in 230 of 381 patients with acute pancreatitis (AP) using endoscopic retrograde cholangiopancreatography. We analyzed factors associated with RAP including the pancreaticobiliary duct system. RAP was diagnosed in 74 patients (19%). Major etiologies of RAP were alcoholic (38%), idiopathic (26%) and pancreaticobiliary malformation (22%). Patients with alcoholic RAP were significantly younger (47.2±11.6 years) than those with gallstone RAP (67.3±16.8; p<0.05). RAP with pancreaticobiliary malformation (male-to-female ratio: 1:4.3; p<0.01) and gallstone RAP (1:1.7; p<0.05) occurred predominantly in females in comparison with alcoholic RAP (1:0.2). Recurrence rate was 80% for AP with pancreaticobiliary malformation, significantly higher than for the others (p<0.01). Pancreas divisum was suspected as the etiology of mild RAP in 7 patients. Four RAP patients with pancreas divisum underwent endoscopic minor papilla sphincterotomy and improved. Pancreaticobiliary maljunction with biliary dilatation (choledochal cyst) was suspected as the etiology of mild RAP in 3 patients. The 3 RAP patients with choledochal cyst underwent prophylactic flow diversion surgery with complete resection of the dilated common bile duct, and achieved improvement. High confluence of pancreaticobiliary ducts was suspected as the etiology of mild RAP in 6 patients. Pancreaticobiliary malformation is one of the major causes of RAP. As some of them benefit from endoscopic or surgical treatment, morphology of the pancreaticobiliary duct system should be examined where possible in RAP patients.

Annular pancreas with high confluence of pancreaticobiliary ducts in an adult

Annular pancreas with high confluence of pancreaticobiliary ducts in an adult

Pancreaticobiliary Maljunction

Pancreaticobiliary maljunction (PBM) is a congenital anomaly defined as a junction of the pancreatic and bile ducts located outside the duodenal wall, usually forming a markedly long common channel. In PBM patients, this anomaly allows regurgitation between the pancreatobiliary and biliopancreatic tract. Since hydrostatic pressure within the pancreatic duct is usually higher than that in the common bile duct, pancreatic juice frequently refluxes into the bile duct. As a result, pancreatic enzyme levels are generally very high in the bile and there is a related high incidence of biliary cancer. PBM can be divided into PBM with biliary dilatation (congenital choledochal cyst [CCC]) and PBM without biliary dilatation (maximal diameter of the bile duct <or= 10 mm). In 42 CCC patients, bile duct and gallbladder cancer was seen in 7 and in 8, respectively. In 49 PBM patients without biliary dilatation, only gallbladder cancer was detected in 33 patients. Because of the increased cell proliferation with random K-ras mutations, the gallbladder mucosa of PBM patients should be considered premalignant. CCC treatment is prophylactic flow-diversion surgery, but only prophylactic cholecystectomy is usually performed for PBM without biliary dilatation. Pancreatobiliary reflux and premalignant changes in the gallbladder can occur in patients with a relatively long common channel (high confluence of pancreaticobiliary ducts).

The presence of a common channel and associated pancreaticobiliary diseases: A prospective ERCP study

Background There are few endoscopic retrograde cholangiographic studies dealing with the relationship between the presence of a common channel and associated pancreaticobiliary diseases. Aims To endoscopically determine the incidence of common channels and assess whether the anatomy of the pancreaticobiliary ductal drainage into the duodenum has any bearing on pancreaticobiliary diseases. Patients and Methods We prospectively examined a common channel formation in 354 endoscopic retrograde cholangiographic cases. Cases with a common channel were divided into three groups: pancreaticobiliary maljunction, high confluence of pancreaticobiliary ducts with a common channel ≥6 mm in which the communication was occluded with the sphincter contraction, and common channel ≤5 mm in length. Results A common channel was observed in 131 cases (37.0%) including 11 with pancreaticobiliary maljunction and 13 with high confluence of pancreaticobiliary ducts. In cases with a common channel, the incidences of associated gallbladder carcinoma and acute pancreatitis were both 11.5%, which were significantly higher than 1.8% and 4.9% seen in cases without a common channel. In pancreaticobiliary maljunction cases, incidence of associated gallbladder carcinoma was 72.7%. Conclusion The presence of an obvious common channel was observed in 37.0%. A close relationship is suggested between the presence of a common channel and development of gallbladder carcinoma and acute pancreatitis.

Acute pancreatitis and a long common channel

As sphincter action does not functionally affect the union in pancreaticobiliary maljunction (PBM), two-way regurgitation occurs. We investigated the features of acute pancreatitis associated with patients displaying a long common channel. We reviewed 3210 endoscopic retrograde cholangiopancreatograms. PBM was diagnosed in 107 patients with a long common channel in which communication between the pancreatic and bile duct was maintained even during sphincter contraction. High confluence of pancreaticobiliary ducts (HCPBD) was diagnosed in 60 patients with a common channel >or=6 mm long in which communication between the two ducts was occluded with sphincter contraction. Of patients with PBM, four had acute pancreatitis. Etiology of acute pancreatitis in the two patients was suspected to involve impaction in a long common channel. Of patients with HCPBD, 17 displayed acute pancreatitis. Three patients had a history of excessive alcohol intake and 10 patients were associated with choledocholithiasis or cholecystitis. The remaining four patients had no history of them. Acute pancreatitis occurs in 13% of patients with a long common channel. Obstruction of a long common channel by stones easily induces bile flow into the pancreas. Even if no obstruction is present, biliopancreatic reflux induces acute pancreatitis in some patients.

LESIONS WITH A HIGH RISK OF CARCINOGENESIS IN THE GALLBLADDER OF PATIENTS WITH A LONG COMMON CHANNEL

Background: Pancreaticobiliary maljunction (PBM) is characterized by a markedly long common channel. In this condition, the sphincter of Oddi does not functionally affect the junction of the pancreatic and bile ducts. Reflux of pancreatic juice into the biliary duct of patients with PBM occurs, resulting in a high incidence of carcinogenesis in the gallbladder. Hence, the gallbladder mucosa of PBM appears to be in a precancerous state. However, the relationship between a relatively long common channel and precancerous lesions of the gallbladder is unknown. The present study aimed to investigate histopathological changes in the gallbladder of patients with a relatively long common channel.Methods: High confluence of pancreaticobiliary ducts (HCPBD) was defined as presence of a common channel ≥ 6 mm in which communication between the pancreatic and bile ducts was disrupted with sphincter contraction. We histopathologically examined the resected or autopsied gallbladder specimens from patients with HCPBD (n = 20), PBM without biliary dilatation (n = 15) and controls (n = 10); focusing on mucosal height and hyperplastic change. Proliferation activity was also examined with Ki‐67 immunostaining.Results: The gallbladder mucosa was significantly higher in PBM and HCPBD than in controls. Hyperplastic mucosal changes were detected more frequently in PBM (73.3%, P &lt; 0.01 vs controls) and in HCPBD (45.0%, P &lt; 0.05 vs controls). Ki‐67 labeling index of the gallbladder epithelium was significantly higher in both PBM and HCPBD than in controls (P &lt; 0.01).Conclusions: In HCPBD, the gallbladder mucosa displayed hyperplastic changes with increased cellular kinetics and appeared precancerous, with a similar appearance to that in PBM.

Pancreatographic findings in idiopathic acute pancreatitis

Despite extensive evaluation based on clinical history, biochemical tests, and noninvasive imaging studies, the cause of acute pancreatitis cannot be determined in 10 to 30% of patients, and a diagnosis of idiopathic acute pancreatitis is made. The purpose of this study was to clarify the pancreatographic findings in patients with idiopathic acute pancreatitis. Endoscopic retrograde cholangiopancreatography (ERCP) was performed in 34 patients with idiopathic acute pancreatitis, and the pancreatographic findings were examined. Patency of the accessory pancreatic duct was examined by dye-injection endoscopic retrograde pancreatography (ERP) in 16 of the 34 patients. In 11 patients (32%), the following anatomic abnormalities of the pancreatic or biliary system were demonstrated: complete pancreas divisum (n = 5), incomplete pancreas divisum (n = 2), high confluence of pancreaticobiliary ducts (n = 2), choledochocele (n = 1), and giant periampullary diverticulum (n = 1). Pancreatographic findings were normal in 17 patients. Eleven of these patients were examined by dye-injection ERP, and all were found to have nonpatent accessory pancreatic duct. Anatomic abnormality of the pancreatic or biliary system is one of the major causes of idiopathic acute pancreatitis. Closure of the accessory pancreatic duct may play a role in the development of idiopathic acute pancreatitis in patients with a normal pancreaticobiliary ductal system.

Pathologic changes in the non-carcinomatous epithelium of the gallbladder in patients with a relatively long common channel

Background Except for pancreaticobiliary maljunction, the relationship between a relatively long common channel and gallbladder carcinoma is unknown. Methods For purposes of this study, a high confluence of pancreaticobiliary ducts was defined as a common channel that is 6 mm or greater in length, together with occlusion of the communication between the pancreatic and bile ducts during sphincter contraction. Pancreaticobiliary maljunction and high confluence of the pancreaticobiliary ducts were detected in 69 (2.1%) and 54 (1.6%), respectively, of 3300 consecutive patients who underwent ERCP. Proliferation activity and genetic alteration were examined in the non-carcinomatous epithelium of the gallbladder in patients with these two radiographic findings at ERCP. Results The Ki-67 labeling index in the epithelium in cases of a high confluence of the pancreaticobiliary ducts and pancreaticobiliary maljunction without biliary dilatation was significantly greater than that in cases of gallbladder carcinoma without these anomalies ( p < 0.01). Overexpression of p53 and K-ras mutations were detected in, respectively, 22.2% and 27.8% of cases of a high confluence of pancreaticobiliary ducts. Conclusions A relatively long common channel may be an important risk factor for the development of gallbladder carcinoma. Vigilance for the development of gallbladder carcinoma is indicated in patients with a relatively long common channel, in addition to those with pancreaticobiliary maljunction.

Common Channel Formation and Associated Pancreaticobiliary Disease: Prospective Study by ERCP

Background/Aims: Common channel formation has been examined in the resected or postmortem specimens, and the incidence ranged from 55 to 91%. Pancreaticobiliary maljunction with a long common channel causes many pancreatic or biliary diseases due to the two-way regurgitation. However, there are few studies on the length of the common channel and associated diseases. Aim of this study is to examine the incidence of the common channel formation that could be diagnosed by ERCP and assess whether the anatomy of the pancreaticobiliary ductal drainage into the duodenum has any relationship with pancreaticobiliary diseases. Methods: We examined prospectively the formation of the common channel by ERCP in almost serial 208 cases from 2001 to 2003. We diagnosed as separate opening, when there are 2 separate orifices at the papilla endoscopically (complete separation), or the common channel was not detected by injection of contrast material with the catheter tip only just within the single orifice (incomplete separation). The length of the common channel was measured radiologically. Cases forming the common channel were divided into 3 groups as follows: pancreaticobiliary maljunction with a long common channel, high confluence of pancreaticobiliary ducts with the common channel 6 mm or longer in which the communication between the pancreatic and bile ducts destroyed with contraction of the sphincter, common channel between 2 and 5 mm. Results: Formation of the common channel was observed in 43 cases (20.7%); 7 pancreaticobiliary maljunction, 8 high confluence of pancreaticobiliary ducts and others. Complete separation was detected in 29 cases. Age on ERCP and sex ratio did not differ in the formation or length of the common channel. Gall stones were associated in 32.6% of cases with the common channel and 29.7% of cases without. Pancreatic carcinoma was 11.6% of cases with the common channel and 17.6% of cases without. The incidences of associated acute pancreatitis and gallbladder carcinoma in cases with the common channel were 18.6% and 16.2%, which were significantly higher than 4.2% and 0.6% of cases without (p<0.01). Conclusions: Formation of the obvious common channel was observed only 20.6% under ERCP study. A close relationship is suggested between the formation of the common channel and development of acute pancreatitis and gallbladder carcinoma.

Pancreatographic Findings of Idiopathic Acute Pancreatitis

Background/Aims: Despite extensive evaluation based on clinical history, biochemical tests, and noninvasive imaging studies, a cause is not established in 10 to 30% of acute pancreatitis cases and a diagnosis of idiopathic acute pancreatitis is made. Aim of this study is to clarify the pancreatographic findings of patients with idiopathic acute pancreatitis. Methods: We performed ERCP in 187 patients with acute pancreatitis after clinical and biochemical resolution of pancreatitis. Thirty-six patients (20 males and 16 females, average age 48.1 years at diagnosis) were diagnosed as having idiopathic acute pancreatitis. Exclusion criteria for idiopathic acute pancreatitis were a history of alcohol abuse; evidence of cholelithiasis and/or choledocholithiasis on US, CT, and ERCP; hypercalcemia; hyperlipidemia; history of trauma; postoperative state; chronic pancreatitis; and having ingested a drug known to be associated with pancreatitis within 1 month of examination. No patients had family histories of pancreatitis. Pancreatographic findings of these 36 patients were examined. Patency of the accessory pancreatic duct was examined by dye-injection ERP in 17 of the patients. After routine ERP studies, contrast medium containing indigo carmine was injected into the main pancreatic duct through a catheter under usual pressure, and the egress of the dye from the minor duodenal papilla was examined endoscopically. Results: In 13 patients (36%), the following anatomic abnormalities of the pancreatic or biliary system were demonstrated: complete pancreas divisum (n=5), incomplete pancreas divisum (n=2), congenital choledochal cyst (n=2), high confluence of pancreaticobiliary ducts (n=2), choledochocele (n=1), and giant periampullary diverticle (n=1). Marked narrow main pancreatic duct was demonstrated in 3 patients, and 3 patients showed a slightly dilated entire main pancreatic duct suggesting papillary stenosis. Pancreatographic findings were normal in the remaining17 patients. Eleven of these 17 patients were examined by dye-injection ERP, and all were found to have nonpatent accessory pancreatic duct. Conclusions: Anatomic abnormality of the pancreatic or biliary system was one of the major causes of idiopathic acute pancreatitis. Nonpatency of the accessory pancreatic duct might play a role in the development of idiopathic acute pancreatitis in the normal cholangiopancreatic ductal system.

Clinical Significance of a Long Common Channel

Background/Aim: It was reported that in only 19 (11%) of 173 patients was the common channel at the junction of the pancreatic and bile ducts found to be 6 mm or longer. Pancreaticobiliary maljunction (PBM) is defined as an anomaly with a markedly long common channel with the junction located outside the duodenal wall, so the action of the sphincter of Oddi does not functionally affect the junction. We defined high confluence of pancreaticobiliary ducts (HCPBD) as a length of the common channel ≧6 mm, in which the communication between the pancreatic and bile ducts was occluded when the sphincter was contracted. This study aims at investigating the clinical significance of HCPBD. Methods: 2,980 consecutive cases with an adequate endoscopic retrograde cholangiopancreatography were reviewed. PBM and HCPBD were diagnosed according to the above definitions. PBM was divided into two groups: with or without biliary dilatation. Results: PBM and HCPBD were detected in 63 (2.1%) and 50 (1.7%) cases, respectively. Biliary dilatation was detected in 30 cases having PBM. The incidences of gallbladder carcinoma associated with PBM with or without biliary dilatation and HCPBD were 13, 67, and 12%, being significantly higher than in controls (p < 0.05, p < 0.01, and p < 0.05). Pancreatic ductal reflux was detected in 11 (85%) of 13 patients with HCPBD in whom postoperative T tube cholangiograms were performed, and acute pancreatitis occurred in 14 (24%) of the 50 patients with HCPBD. Conclusions: HCPBD may be an intermediate variant of PBM. It is necessary to pay attention to an associated gallbladder carcinoma in patients with HCPBD as well as in those with PBM.