0:01

So this is a patient in his 70s,

0:04

who presents with jaundice and an MRI

0:06

was done to further evaluate this.

0:08

So we'll start off with our axial T2-weighted

0:10

images and coronal T2-weighted images.

0:13

Lots of dilated bile ducts, right

0:15

and left, very, very dilated.

0:18

And so there's some abnormality that's

0:19

resulting in obstruction of the bile ducts.

0:21

We can scroll all the way downwards.

0:24

Tough to see anything discrete.

0:26

Certainly no choledocholithiasis

0:28

or something benign like that.

0:30

The other thing you notice is the

0:31

pancreatic duct is quite dilated as well.

0:34

And you can see that all the way

0:35

here to the ampulla, right there.

0:39

If we look at the common bile duct on the

0:41

coronal images, we see that there is a relative

0:44

abrupt cutoff of the common bile duct as well.

0:46

It's quite dilated, and as you get distally, it

0:48

just sort of gets abruptly smaller.

0:51

Similarly with the pancreatic duct,

0:53

it's quite dilated, and as you get

0:54

out here, it just gets smaller.

0:57

And so we've seen a few cases of, you know,

0:59

certainly a lot of cases of strictures

1:00

causing biliary ductal dilatation.

1:03

When you see, you know, the bile duct dilated

1:05

to this degree, it's not unreasonable to think

1:08

that there could be a bile duct dilation.

1:09

Distal common bile duct stricture from a

1:12

malignancy such as a cholangiocarcinoma.

1:14

And I think that may be

1:15

something to think about.

1:17

In this instance, there's also pancreatic

1:19

ductal dilatation, which again,

1:22

you may have soft tissue from the

1:23

cholangiocarcinoma potentially extending

1:25

into the pancreas causing ductal dilation.

1:27

That's certainly a thought

1:28

you could consider.

1:29

Another possibility is that this

1:31

is a lesion right at the ampulla

1:33

causing what we call the double duct sign.

1:35

So you can see that beautifully on the screen.

1:38

3D MRCP image, this double duct sign

1:40

of both the pancreatic and common bile

1:42

ducts that are dilated, and that just

1:44

tells you that there's a single lesion

1:47

that's resulting in dilatation of both.

1:49

And the reason I wanted to show this case is,

1:51

you know, one may consider this potentially

1:53

a cholangiocarcinoma causing pancreatic

1:55

ductal dilatation, but this in fact turned

1:57

out to be a primary pancreatic neoplasm that

2:01

resulted in this sort of double duct sign.

2:04

Tougher to see on the post-contrast sequences.

2:06

I'll show you some of the pre- and post-contrast

2:08

sequences where there's a bit of motion.

2:10

So it's tough to see if

2:12

there's anything right there.

2:13

You can see the post-contrast sequence here.

2:15

You know, maybe there's something very ill

2:17

defined, but in this instance, I found that the

2:20

diffusion-weighted imaging was quite useful.

2:22

And oftentimes I can make most of the

2:25

diagnoses that I need to make without using

2:28

diffusion, but particularly when it comes

2:30

to things in the pancreas, I found that

2:32

diffusion-weighted imaging is often useful.

2:35

So if we look at our ADC map over here, we can

2:37

see that you have the pancreatic duct that's

2:41

dilated, the biliary duct that's

2:43

dilated, and right around here, a focal region of

2:46

hypointense signal, right over here as well.

2:50

If you look at DWI, you can see that.

2:52

That area corresponds to

2:54

an area of hyperintensity.

2:55

So this turned out to be a pancreatic neoplasm.

2:58

You may have also noticed numerous

2:59

liver masses, which are the

3:00

metastases of the pancreatic neoplasm.

3:02

And so this turned out to be a

3:03

pancreatic neoplasm resulting in dilatation

3:05

of not only the pancreatic duct,

3:07

but also of the common bile duct.

3:09

So whenever you see biliary ductal

3:10

dilatation, always look at adjacent

3:13

organs, such as the pancreas, and look closely

3:16

at the ampulla to make sure that there

3:18

is no lesion located there that may be

3:20

resulting in the biliary ductal obstruction.