Pancreatic

Duct Obstruction:

A New Observation Transhepatic

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PATRICK

C. FREENY1

AND

,

An 80-year-old jaundice,

male

might upper

at another

hospital

was seen

included

phy and barium examinations and colon. A aeTc sulfur

areas

of photon

activity

in the

and chronic

deficiency

spine.

by

bile plugs.

Liver

normal

onset

Initial

evaluation

intravenous

in

the

changes,

night

lobe

liven

biopsy

edema

were

abnormal:

and

465 lU/liter;

100 ml. treatment

Initial impression was initiated.

elevated

of

acute

tniads with

night

intrahepatic

were

minimally

dium

refluxed

filling

of the

Section

of Gastroenterology

Am J Roentgenol © 1978 American

and

1978

the

total bilirubin,

2.2 mgI

hepatitis

medical

active

to treatment

previous

ducts

canalicular

phos-

freely distal

levels.

the

portion

and

led to transfer

Gray

scale

good

to

ultrason-

of the

main

intrahepatic

duct,

duct.

the

filling tapered

ducts right

pancreatic

was

show distortion, intrahepatic

focal ducts

is abrupt

and

and side

could

possible

in

material

duct

terminus

me-

facilitate placed

contrast

suggested

duct

To

patient

of the main duct

ducts

contrast

and additional

of findings

Many

left

pancreatic

of the

finely

The

cholangiography,

main

position

Intrahepatic

(arrows).

iA).

During

into

Despite

1.-A,

(fig.

dilated.

branches, a normal, identified (fig. 1B). The combination

not

be

carcinoma

stenoses, failed to

nodular

and

B, (arrow) fill.

obstruction.

April 14, 1978.

Mason Clinic, 1 100 Ninth Avenue, Seattle, Liver and Biliary Tract Disorders, Mason Clinic,

131 :521-522, September Roentgen Ray Society

from

was injected.

Terminus indicating

2

was

response

oblique

Fig.

after revision

SGOT, 44 lU/liter;

a left posterior

occlusions

Received January 31 , 1978; accepted , Department of Diagnostic Radiology,

JR.2

ography showed a 3 cm mass in the tail of the pancreas, an enlarged liver, and dilated left intrahepatic bile ducts. Fine needle percutaneous transhepatic cholangiography demonstrated normal extrahepatic biliany ducts with distortion, displacement, smooth encasement, and focal stenoses of the

increased

alkaline

ROSOFF,

phatase,

slightly

tract mottled

showed

of portal

leukocytes,

tests

and

LEONARD

Lack of satisfactory

cholangiogna-

of the upper gastrointestinal colloid liver scan showed

polymorphonuclear

function

of acute

and fever.

Percutaneous

inflammatory

infiltration

because

pain,

Percutaneous

the Virginia Mason Medical Center 3 weeks later. On arrival, the patient was jaundiced and febnile, and complained of night upper abdominal pain. Values of liver function tests were

Report

quadrant

Fine Needle

Cholangiography

Reflux of contrast medium from the common bile duct into the main pancreatic duct has been observed during surgical and T-tube cholangiognaphy [1 2]. Usually only a short segment of the pancreatic duct fills, and this is noted merely as an incidental finding. We report a case in which neoplastic obstruction of the main pancreatic duct was demonstrated during fine needle percutaneous transhepatic cholangiography.

Case

during

521

Washington

Seattle,

981 1 1

Washington

.

Address

reprint

requests

to P. C. Freeny.

981 1 1.

0361 -803X/78/0900-0521

$00.00

CASE

522

REPORTS even, despite the patient,

repeated the normal

identified.

The

cluded cneatic

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noma This

tail

case

the

pancreatic

attempts occurs,

may

a new duct.

and

We

patient

adequately

during

into

the

free

repeat

pancreatic

valuable

pancreatic

if

and

of

forceful

the

however,

give

percu-

recommend

material

opacify

carci-

obstruction

positioning

circumstances,

panwas

metastases.

seen

do not

contrast

oc-

distal which

liven

finding

cholangiography;

careful

certain

with

cholangiography:

to neflux during

distorted

of be

not

pathologically:

pancreas

illustrates

tnanshepatic

main

the

and

of the

taneous

duct

of

repositioning could

ducts and the obstructed to the connect diagnosis,

angiognaphically of the

and terminus

combination

intrahepatic duct led

confirmed

injections ductal

reflux

injections

duct

and,

in

information.

REFERENCES 1

.

Berk

RN

Ducts.

Clemett

,

AR : Radiology

Philadelphia,

of the Gallbladder

Saunders,

and Bile

1977

2. Hatfield

Fig.

2.

Normal

-

pancreatic

duct

terminus

is smooth

and finely

PM, Wise RE: Radiology of the Gallbladder and Bile Ducts. Baltimore, Williams & Wilkins, 1976 3. Femnucci JT Jr, Wittenberg J, Sarno RA, Dreyfus JA: Fineneedle transhepatic cholangiography: a new approach to obstructive jaundice. Am J Roentgenol 127:403-407, 1976

tapered

(arrows).

4. of

the

tail

of

the

pancreas

angiognaphy performed the tail of the pancreas

tases.

Repeat

metastatic

liver

electron

as the primary

the

liver.

biopsy

microscopy

site. The patient

expired

a tumor in liver metas-

showed

metastatic

identified

the

1 month

later.

Okuda

K, Tanikawa

pancreas 5.

Pereiras

A Jr,

“skinny” Discussion

Fine phy

needle

has

percutaneous

facilitated

the

the

transhepatic rapid

of

on forked main

pancreatic duct follows a variety of courses, at the splenic hilum in a finely tapered single

duct

duct

and

(fig.

2) [11,

side

branches

normal ductal terminus In our patient, filling side

branches

was

12].

Filling with

of the failure

indicates obstruction of the main pancreatic

observed

during

fluonoscopy;

fill

diagnosis

RO,

a rapid,

of

Greenwald

simple Ann

cholestasis.

the

[10, 11]. duct and how-

EA, Vennes

Endoscopic liver 7.

Evans

JA:

5, Jinnouchi

5,

AA,

Schiff

ER:

The

and accurate method Intern Med 86:562-568,

in 10.

Gastrointest Specialized

the

diagnosis PC,

the

Ball

of

signs.

691,

ii. 12.

in

bile

ducts.

TJ:

pancreatic

in

of pancreatic

and

carcinoma.

of

of

ab-

appearance of Radiology 102:259-

endoscopic

angiography

Am

in

1964

1 19 :271-274,

Evaluation

HJ:

1976

investigation

carcinoma:

Radiology

cholangiopancreatography

sis

22 :156-159,

Endosc

Bilbao MK, Katon AM: “Blind” retrograde cholangiopancreatography

and other

Freeny

of

CA, Ansel

cholangiognaphy

techniques

carcinoma

266, 1972 Freeny PC, endoscopic duct”

SE, Aohrmann

intrahepatic

disease. Radiology 82:579-594, DA, Camlson HC: Cholangiographic

primary

9.

JA, Silvis

retrograde

diseases.

dominal 8. Legge

proximal to

Chiprut

needle:

6. Ayoola

jaundiced

patients [3-5). Those patients with jaundice due to cancinoma of the pancreas usually have extrahepatic bile duct obstruction at the level of the porta hepatis on intnapancneatic common bile duct [3, 5]. The morphologic characteristics of neoplastic obstruction of the bile duct are well known [6-8]. Endoscopic netnognade cnolangiopancreatography has shown that the most common finding of pancreatic carcinoma is obstruction of the main pancreatic duct, with frequent encasement or obstnuction of the contiguous common bile duct [9, 10]. The normal terminating

T, Kauratomi

1977

cholangiogna-

evaluation

K, Emura

Umabe K, Sumikoshi T, Kanda Y, Fukuyama Y, Musha H, Mon H, Shimokawa Y, Yakushiji F, Matsuuma Y: Nonsurgical percutaneous transhepatic cholangiog raphy - diagnostic significance in medical problems of the liver. Am J Dig Dis 19:21-36, 1974

Pancreatic

the next day demonstrated and multiple hypovascular

percutaneous

adenocarcinoma;

to

J Roentgenol

evaluation of (ERCP) the ‘ ‘double 1976 retrograde in the

diagno-

130:683-

1978

Rohnmann CA, Silvis SE, Vennes JA: Evaluation of the endoscopic pancreatogram. Radiology 113:297-304, 1974 Vanley PF, Aohrmann CA, Silvis SE, VennesJA: The normal endoscopic pancreatogram . Radiology 1 18 :295-300, 1976