Unusual Mass in the Hepatic Portal of an 86-year-old Woman

Zusammenfassung

Varizen im Ligamentum hepatoduodenale und in der Leberpforte sind normalerweise Folge einer kavernösen Transformation einer verschlossenen Portalvene. Wir stellen den ungewöhnlichen Fall einer asymptomatischen 86-jährigen Patientin mit Varizen des Ductus coledochus vor, welche wegen Verdachts auf ein Cholangiokarzinom an unserer Klinik abgeklärt wurde. Die Diagnose konnte schließlich mit transabdominalem Doppler-Ultraschall gestellt werden. Dieser zeigte multiple erweiterte Gefäße in der Gallengangswand. Die meisten Patienten mit Gallengangsvarizen sind asymptomatisch. Gelegentlich kann es aber zur Dilatation der Gallenwege mit erhöhten Cholestaseparametern oder gar Ikterus kommen.

Abstract

Varicose veins in the hepatoduodenal ligament and hepatic portal are normally due to cavernous transformation of the portal vein. We present an unusual case of varices of the common bile duct in an asymptomatic 86-year-old woman who was referred to our hospital for evaluation of a suspected cholangiocarcinoma. A cholangiocarcinoma could be excluded, however, and the diagnosis of intramural varicosis of the common bile duct was made with transabdominal colour Doppler sonography. Sonography showed multiple dilated vessels in the wall of the common bile duct. Most patients with choledochal varices are asymptomatic. Choledochal varices may, however, result in dilatation of the biliary system, causing raised levels of serum alkaline phosphatase and even jaundice.

Hepatic vein thrombosis - portal hypertension - portal system varicose veins

References

• 1 Spira R, Widrich W C, Keusch K D. et al . Bile duct varices.  Arch Surg. 1985;  120 1194-1196
• 2 Saint J H. The epicholedochal venous plexus and its importance as a means of identifying the common duct during operations on the extrahepatic biliary tract.  Br J Surg. 1961;  48 489-498
• 3 Hymes J L, Haicken B N, Schein C L. Varices of the common bile duct as a surgical hazard.  Am Surg. 1977;  43 686-688
• 4 Tighe M, Jacobsen I. Bleeding from bile duct varices: an unexpected hazard during therapeutic ERCP.  Gastrointest Endosc. 1996;  43 250-252
• 5 Williams S M, Burnett D A, Mazer M J. Radiographic demonstration of common bile duct varices.  Gastrointest Radiol. 1982;  7 69-70
• 6 Bayraktar Y, Balkanci F, Kayhan B. et al . Bile duct varices of “pseudocholangiocarcinoma sign” in portal hypertension due to cavernous transformation of the portal vein.  Am J Gastronterol. 1992;  87 1801-1806
• 7 Gorgul A, Kayhan B, Dogan I. et al . Disappearance of the pseudo-cholangiocarcinoma sign after TIPSS.  Am J Gastroenterol. 1996;  91 150-154
• 8 Chow L, Jeffrey R B Jr. Intramural varices of the bile duct: an unusual pattern of cavernous transformation of the portal vein.  AJR Am J Roentgenol. 1999;  173 1255-1256
• 9 Plikat K, Klebl F, Buchner C. et al . Evaluation of intestinal hyperaemia in inflamed bowel by high resolution contrast harmonic imaging (CHI).  Ultraschall Med. 2004;  25 (4) 257-262
• 10 Ocran K, Rickes S, Heukamp I. et al . Sonographic findings in hepatic involvement of hereditary haemorrhagic telangiectasia.  Ultraschall Med. 2004;  25 (3) 191-194
• 11 Weiler H, Grandel A, Fruhmorgen P. Congenital cystic dilatation of the cystic duct associated with an anomalous panceraticobiliary ductal junction.  Ultraschall Med. 2003;  24 (3) 197-201
• 12 Song M H, Kim M H, Lee S K. et al . Bile duct varices.  Gastrointest Endosc. 2004;  59 (7) 869-870
• 13 Palazzo L, Hochain P, Helmer C. et al . Biliary varices on endoscopic ultrasonography: clinical presentation and outcome.  Endoscopy. 2000;  32 (7) 520-524
• 14 Leclerc J C, Cannard L, Debelle L. et al . MIR of portal cavernoma with biliary involvement.  J Radiol. 2002;  83 (3) 341-349
• 15 Condat B, Vilgrain V, Asselah T. et al . Portal cavernoma-associated cholangiopathy: a clinical and MR cholangiography coupled with MR portography imaging study.  Hepatology. 2003;  37 (6) 1302-1308