Periampullary diverticulum

Case contributed by Dr Varun Babu

Presentation

Chronic liver disease patient with gall stone. Now presented with upper abdominal pain. To rule out any hepatic neoplasm and biliary inflammation

Patient Data

Age: 70 years
Gender: Female
CT

Plain study followed by triphasic liver study

Liver shows features of chronic parenchymal disease in the form of surface and parenchymal nodularity, widened interlobar fissure, left and caudate lobe hypertrophy. Patchy wedge shaped geographic areas of subtle arterial enhancement in the peripheries seen in both lobes becoming more evident in portal  phase and homogenizing in equilibrium phase. 

Mild irregular mural thickening of gall bladder with mild pericholecystic free fluid. A 4mm radiodense gall stone seen. 

Well defined lesion with air fluid levels and thin walls seen in periampullary region communicating with duodenum, displacing distal common bile duct and distal main pancreatic duct posteriorly. 

No splenomegaly or ascites. No significant portosystemic collaterals. Gastric band in situ. 

MRI

The lesion with air fluid levels in periampullary region does not communicate with the biliary tree and is just displacing the ducts posteriorly. The gall bladder mural thickening is more pronounced and easily visualized in MRI. Some of the arterially enhancing hepatic areas show diffusion restriction.  

Case Discussion

The cystic lesion with air fluid levels in the periampullary region is typical of a duodenal diverticulum. There is feature of mild inflammation of the gall bladder, likely calcular cholecystitis. Even though the diverticulum exerts some mass effect in the distal biliary tree, there is no back pressure changes in imaging nor clinically. 

As regards to the variant hepatic attenuation, geographic periportal patchy arterial enhancement occurs in chronic liver disease both in tumoral and non tumoral arterioportal shunting. With multiphase imaging, the distinction is made with no demonstrable washout in the equilibrium favoring benign intrahepatic arterioportal shunting.  However this warrants close follow up, as any of these site could harbor the next tumor. 

This patient had a previous MRI done (one year back, images not included as DICOM files not available). There is no appreciable interval difference in the hepatic attenuation, yet again favoring a non tumoral picture. 

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Case information

rID: 55182
Case created: 24th Aug 2017
Last edited: 24th Aug 2017
Inclusion in quiz mode: Included
Institution: Vivid Diagnostic Centre

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