53-year-old female with right upper quadrant pain and epigastric pain x3 days ABDOMEN:LIVER, BILIARY TRACT: Scattered subcentimeter T2 hyperintense lesions throughout the liver compatible with cysts. Redemonstrated is mild to moderate intrahepatic biliary ductal dilatation. The common hepatic duct is dilated measuring 9 mm, not significantly changed when compared to the prior exam dated 11/3/2007. There is anomalous pancreaticobiliary junction with insertion of the pancreatic duct proximal to the ampulla. There is a smooth tapered appearance of the distal common bile duct with beading and narrowing involving the distal common bile duct, pancreaticobiliary junction, and duct distal to the junction leading to the ampulla.Abnormal appearance of the ampulla with a port catheter in the duodenum which raises the possibility of prior procedure such as a sphincterotomy. There is no evidence of fistula to the bowel. No inflammatory changes to suggest infection.Pneumobilia is again noted, not significantly changed since recent CT. SPLEEN: No significant abnormality noted.PANCREAS: Main pancreatic duct measures up to 4 mm.ADRENAL GLANDS: No significant abnormality noted.PneuKIDNEYS, URETERS: No significant abnormality noted.RETROPERITONEUM, LYMPH NODES: No significant abnormality noted.BOWEL, MESENTERY: Left lower quadrant ostomy is again noted.BONES, SOFT TISSUES: No significant abnormality noted.OTHER: No significant abnormality noted.
1.Beaded stricturing involving the distal common bile duct, pancreatic or biliary junction, and duct distal to the junction. Provided an anomalous pancreaticobiliary junction with insertion of the main pancreatic duct proximal to the ampulla, this stricturing explains the prominence of both the CBD and main pancreatic duct. There has been no significant change in CBD caliber since 2007 examination. Pneumobilia is new since 2007, not significantly changed since recent CT.2.Prominence of the pancreatic head with decreased enhancement without mass effect on the main pancreatic duct.3.Outward tethering of the duodenum and abnormal appearance of the ampulla raises the possibility of prior procedure such as a sphincterotomy. Correlation with past procedure/surgical history is necessary.4.The above-mentioned findings are favored to reflect an inflammatory process, such as post-procedural stricture or HIV cholangiopathy, that involves the bile ducts as opposed to pancreatic head mass. ERCP with biopsy may be considered.Findings discussed with Dr. Murray at 1016 on 10/31/16. 