Skip to main content
SpringerLink
Log in

Bile duct penetrating duodenal wall sign: a novel computed tomography finding of common bile duct stone impaction into duodenal major papilla

  • Original Article
  • Published:
Japanese Journal of Radiology Aims and scope Submit manuscript

Abstract

Purpose

Impacted common bile duct stones cause severe acute cholangitis. However, the early and accurate diagnosis, especially iso-attenuating stone impaction, is still challenging. Therefore, we proposed and validated the bile duct penetrating duodenal wall sign (BPDS), which shows the common bile duct penetrating the duodenal wall on coronal reformatted computed tomography (CT), as a novel sign of stone impaction.

Methods

Patients who underwent urgent endoscopic retrograde cholangiopancreatography (ERCP) for acute cholangitis due to common bile duct stones were retrospectively enrolled. Stone impaction was defined by endoscopic findings as a reference standard. Two abdominal radiologists blinded to clinical information interpreted CT images to record the presence of the BPDS. The diagnostic accuracy of the BPDS to diagnose stone impaction was analyzed. Clinical data related to the severity of acute cholangitis were compared between patients with and without the BPDS.

Results

A total of 40 patients (mean age 70.6 years; 18 female) were enrolled. The BPDS was observed in 15 patients. Stone impaction occurred in 13/40 (32.5%) cases. Overall accuracy, sensitivity, and specificity were 34/40 (85.0%), 11/13 (84.6%), and 23/27 (85.2%), respectively; 14/16 (87.5%), 5/6 (83.3%), and 9/10 (90.0%) for iso-attenuating stones; and 20/24 (83.3%), 6/7 (85.7%), and 14/17 (82.4%) for high-attenuating stones. Interobserver agreement of the BPDS was substantial (κ = 0.68). In addition, the BPDS was significantly correlated with the number of factors in the systemic inflammatory response syndrome (P = 0.03) and total bilirubin (P = 0.04).

Conclusion

The BPDS was a unique CT imaging finding to identify common bile duct stone impaction regardless of stone attenuation with high accuracy.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

Abbreviations

BPDS:

Bile duct penetrating duodenal wall sign

CT:

Computed tomography

ERCP:

Endoscopic retrograde cholangiopancreatography

SIRS:

Systemic inflammatory response syndrome

MRCP:

Magnetic resonance cholangiopancreatography

References

  1. Miura F, Okamoto K, Takada T, Strasberg SM, Asbun HJ, Pitt HA, et al. Tokyo guidelines 2018: initial management of acute biliary infection and flowchart for acute cholangitis. J Hepatobiliary Pancreat Sci. 2018;25(1):31–40.

    Article  PubMed  Google Scholar 

  2. Yeom DH, Oh HJ, Son YW, Kim TH. What are the risk factors for acute suppurative cholangitis caused by common bile duct stones? Gut Liver. 2010;4(3):363–7.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Balthazar EJ, Birnbaum BA, Naidich M. Acute cholangitis: CT evaluation. J Comput Assist Tomogr. 1993;17(2):283–9.

    Article  CAS  PubMed  Google Scholar 

  4. Zidi SH, Prat F, Le Guen O, Rondeau Y, Rocher L, Fritsch J, et al. Use of magnetic resonance cholangiography in the diagnosis of choledocholithiasis: prospective comparison with a reference imaging method. Gut. 1999;44(1):118–22.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  5. Gandolfi L, Torresan F, Solmi L, Puccetti A. The role of ultrasound in biliary and pancreatic diseases. Eur J Ultrasound. 2003;16(3):141–59.

    Article  PubMed  Google Scholar 

  6. Laokpessi A, Bouillet P, Sautereau D, Cessot F, Desport JC, Le Sidaner A, et al. Value of magnetic resonance cholangiography in the preoperative diagnosis of common bile duct stones. Am J Gastroenterol. 2001;96(8):2354–9.

    Article  CAS  PubMed  Google Scholar 

  7. Verma D, Kapadia A, Eisen GM, Adler DG. EUS vs MRCP for detection of choledocholithiasis. Gastrointest Endosc. 2006;64(2):248–54.

    Article  PubMed  Google Scholar 

  8. Tse F, Liu L, Barkun AN, Armstrong D, Moayyedi P. EUS: a meta-analysis of test performance in suspected choledocholithiasis. Gastrointest Endosc. 2008;67(2):235–44.

    Article  PubMed  Google Scholar 

  9. Tso DK, Almeida RR, Prabhakar AM, Singh AK, Raja AS, Flores EJ. Accuracy and timeliness of an abbreviated emergency department MRCP protocol for choledocholithiasis. Emerg Radiol. 2019;26(4):427–32.

    Article  PubMed  Google Scholar 

  10. Ely R, Long B, Koyfman A. The emergency medicine-focused review of cholangitis. J Emerg Med. 2018;54(1):64–72.

    Article  PubMed  Google Scholar 

  11. Bone RC, Balk RA, Cerra FB, Dellinger RP, Fein AM, Knaus WA, et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis The ACCP/SCCM consensus conference committee American college of chest physicians/society of critical care medicine. Chest. 1992;101(6):1644–55.

    Article  CAS  PubMed  Google Scholar 

  12. Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, et al. Classification of acute pancreatitis–2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013;62(1):102–11.

    Article  PubMed  Google Scholar 

  13. Joo KR, Cha JM, Jung SW, Shin HP, Lee JI, Suh YJ, et al. Case review of impacted bile duct stone at duodenal papilla: detection and endoscopic treatment. Yonsei Med J. 2010;51(4):534–9.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Binmoeller KF, Katon RM. Needle knife papillotomy for an impacted common bile duct stone during pregnancy. Gastrointest Endosc. 1990;36(6):607–9.

    Article  CAS  PubMed  Google Scholar 

  15. Leung JW, Banez VP, Chung SC. Precut (needle knife) papillotomy for impacted common bile duct stone at the ampulla. Am J Gastroenterol. 1990;85(8):991–3.

    CAS  PubMed  Google Scholar 

  16. Kiriyama S, Kozaka K, Takada T, Strasberg SM, Pitt HA, Gabata T, et al. Tokyo guidelines 2018: diagnostic criteria and severity grading of acute cholangitis (with videos). J Hepatobiliary Pancreat Sci. 2018;25(1):17–30.

    Article  PubMed  Google Scholar 

  17. Lan Cheong Wah D, Christophi C, Muralidharan V. Acute cholangitis: current concepts. ANZ J Surg. 2017;87(7–8):554–9.

    Article  PubMed  Google Scholar 

  18. Tseng CW, Chen CC, Chen TS, Chang FY, Lin HC, Lee SD. Can computed tomography with coronal reconstruction improve the diagnosis of choledocholithiasis? J Gastroenterol Hepatol. 2008;23(10):1586–9.

    Article  PubMed  Google Scholar 

  19. Pickuth D. Radiologic diagnosis of common bile duct stones. Abdom Imaging. 2000;25(6):618–21.

    Article  CAS  PubMed  Google Scholar 

  20. Gautier G, Pilleul F, Crombe-Ternamian A, Gruner L, Ponchon T, Barth X, et al. Contribution of magnetic resonance cholangiopancreatography to the management of patients with suspected common bile duct stones. Gastroenterol Clin Biol. 2004;28(2):129–34.

    Article  PubMed  Google Scholar 

  21. Boraschi PRG, Braccini G, Lamacchia M, Rossi M, Falaschi F. Detection of common bile duct stones before laparoscopic cholecystectomy. Evaluation with MR cholangiography. Acta Radiol. 2002;43(6):593–8.

    Article  CAS  PubMed  Google Scholar 

  22. Singh A, Mann HS, Thukral CL, Singh NR. Diagnostic accuracy of MRCP as compared to Ultrasound/CT in patients with obstructive Jaundice. J Clin Diagn Res. 2014;8(3):103–7.

    PubMed  PubMed Central  Google Scholar 

  23. Tazuma S. Gallstone disease: epidemiology, pathogenesis, and classification of biliary stones (common bile duct and intrahepatic). Best Pract Res Clin Gastroenterol. 2006;20(6):1075–83.

    Article  PubMed  Google Scholar 

  24. Petrescu I, Bratu AM, Petrescu S, Popa BV, Cristian D, Burcos T. CT vs. MRCP in choledocholithiasis jaundice. J Med Life. 2015;8(2):226–31.

    CAS  PubMed  PubMed Central  Google Scholar 

  25. Jeffrey RB, Federle MP, Laing FC, Wall S, Rego J, Moss AA. Computed tomography of choledocholithiasis. AJR Am J Roentgenol. 1983;140(6):1179–83.

    Article  CAS  PubMed  Google Scholar 

  26. Burdiles P, Csendes A, Diaz JC, Smok G, Bastias J, Palominos G, et al. Histological analysis of liver parenchyma and choledochal wall, and external diameter and intraluminal pressure of the common bile duct in controls and patients with common bile duct stones with and without acute suppurative cholangitis. Hepatogastroenterology. 1989;36(3):143–6.

    CAS  PubMed  Google Scholar 

  27. Shinya S, Sasaki T, Yamashita Y, Kato D, Yamashita K, Nakashima R, et al. Procalcitonin as a useful biomarker for determining the need to perform emergency biliary drainage in cases of acute cholangitis. J Hepatobiliary Pancreat Sci. 2014;21(10):777–85.

    Article  PubMed  Google Scholar 

  28. Umefune G, Kogure H, Hamada T, Isayama H, Ishigaki K, Takagi K, et al. Procalcitonin is a useful biomarker to predict severe acute cholangitis: a single-center prospective study. J Gastroenterol. 2017;52(6):734–45.

    Article  CAS  PubMed  Google Scholar 

  29. Thompson J, Bennion RS, Pitt HA. An analysis of infectious failures in acute cholangitis. HPB Surg. 1994;8(2):139–44.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  30. Hui CK, Lai KC, Yuen MF, Ng M, Lai CL, Lam SK. Acute cholangitis–predictive factors for emergency ERCP. Aliment Pharmacol Ther. 2001;15(10):1633–7.

    Article  CAS  PubMed  Google Scholar 

  31. Takano Y, Nagahama M, Maruoka N, Yamamura E, Ohike N, Norose T, et al. Clinical features of gallstone impaction at the ampulla of Vater and the effectiveness of endoscopic biliary drainage without papillotomy. Endosc Int Open. 2016;4(7):E806–11.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Kamisawa T, Takuma K, Tabata T, Egawa N. Clinical implications of accessory pancreatic duct. World J Gastroenterol. 2010;16(36):4499–503.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Gao W, Masuda A, Matsumoto I, Shinzeki M, Shiomi H, Takenaka M, et al. A case of lymphoepithelial cyst of pancreas with unique “cheerios-like” appearance in EUS. Clin J Gastroenterol. 2012;5(6):388–92.

    Article  PubMed  Google Scholar 

Download references

Funding

All authors disclosed no financial relationships relevant to this study.

Author information

Authors and Affiliations

  1. Department of Medicine, Shiga University of Medical Science, Seta Tsukinowa, Otsu, 520-2192, Japan

    Shuhei Shintani, Osamu Inatomi, Takayuki Imai, Yoshiya Takeda, Takehide Fujimoto, Atushi Nishida & Akira Andoh

  2. Department of Endoscopy, Shiga University of Medical Science, Otsu, Japan

    Shigeki Bamba

  3. Department of Radiology, Shiga University of Medical Science, Otsu, Japan

    Yuki Tomozawa, Akitoshi Inoue, Shinichi Ota & Yoshiyuki Watanabe

  4. Department of Radiology, Nagahama Red Cross Hospital, Nagahama, Japan

    Shinichi Ota

  5. Department of Center for Clinical Research, Shiga University of Medical Science, Otsu, Japan

    Hiromu Kutsumi

Authors
  1. Shuhei Shintani
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Osamu Inatomi
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Shigeki Bamba
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Takayuki Imai
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Yuki Tomozawa
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Akitoshi Inoue
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Shinichi Ota
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Yoshiya Takeda
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Takehide Fujimoto
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Atushi Nishida
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Hiromu Kutsumi
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Yoshiyuki Watanabe
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Akira Andoh
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Osamu Inatomi.

Ethics declarations

Conflict of interest

The authors declare that they have no conflicts of interest.

Ethical approval and consent to participate

The study was conducted in agreement with the Declaration of Helsinki and received approval from the ethics committee of Shiga University of Medical Sciences and conformed to its guidelines (Approval No.: R2020-145).

Consent for publication

Not applicable.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Shintani, S., Inatomi, O., Bamba, S. et al. Bile duct penetrating duodenal wall sign: a novel computed tomography finding of common bile duct stone impaction into duodenal major papilla. Jpn J Radiol 41, 854–862 (2023). https://doi.org/10.1007/s11604-023-01406-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11604-023-01406-1

Keywords

Search

Navigation