G a s t r o i n t e s t i n a l I m a g i n g R ev i ew

Raman and Fishman

CT of the Distal CBD and Ampulla

FOCUS ON:

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Gastrointestinal Imaging
Review

Siva P. Raman1
Elliot K. Fishman
Raman SP, Fishman EK

Abnormalities of the Distal

Common Bile Duct and Ampulla:
Diagnostic Approach and
Differential Diagnosis Using
Multiplanar Reformations and
3D Imaging
OBJECTIVE. The distal common bile duct (CBD) and ampulla are extremely difficult
sites to evaluate on CT. This article seeks to provide the reader with a framework and algorithmic approach to the evaluation of abnormalities involving the distal CBD and ampulla,
including an emphasis on the use of multiplanar reformations and 3D imaging, the morphologic features on CT that suggest the presence of malignancy, and a differential diagnosis for
abnormalities in this location.
CONCLUSION. In our experience, both the distal CBD and ampulla are common sites
of missed diagnoses for radiologists. Avoiding mistakes in interpreting imaging findings in
this location requires a systematic approach especially in the setting of unexplained biliary
ductal dilatation. Rather than simply suggesting that MRCP or ERCP be performed for the
ultimate diagnosis, radiologists can perform a careful CT evaluation using multiplanar reformations and 3D imaging to determine the correct diagnosis prospectively. A timely and correct diagnosis is imperative because lesions in the ampulla and CBD can be very aggressive
despite their small size.

Keywords: 3D imaging, ampulla, ampullary carcinoma,

common bile duct, CT, pancreatic adenocarcinoma
DOI:10.2214/AJR.13.11288
Received May 24, 2013; accepted after revision
July 2, 2013.
1
Both authors: Department of Radiology, Johns Hopkins
University, 601 N Caroline St, JHOC 3251, Baltimore, MD
21287. Address correspondence to S. P. Raman
(srsraman3@gmail.com).

This article is available for credit.

AJR 2014; 203:1728
0361803X/14/203117
American Roentgen Ray Society

he distal common bile duct

(CBD) and ampulla can be an
extremely challenging location
for the radiologist to assess: It
can be difficult not only to differentiate a
normal distal CBD with mild dilatation from
a distal CBD with true pathologic dilatation
but also, even once an abnormality has been
identified, to provide the appropriate differential diagnosis. The accurate radiologic
evaluation of this location is of great importance because periampullary tumors are the
third most common type of gastrointestinal
neoplasm, after colonic and gastric tumors,
and because the different lesions found in
this location can have markedly different
prognoses [1].
This article seeks to provide the reader
with a framework for interpreting CT studies of the distal CBD and ampulla, including
providing a differential diagnosis for ampullary and distal CBD abnormalities and lesions, a perspective on when a dilated CBD
requires further evaluation with MRCP or
ERCP, and a discussion of the use of multiplanar reformations (MPRs) and 3D imaging
to better assess the morphology of the distal CBD and ampulla. Of course, many cas-

es will ultimately require either MRCP or

ERCP for further definitive evaluation, but
an accurate interpretation of the initial CT
examination may allow the radiologist to
prospectively suggest the correct diagnosis.
Evaluation of Biliary Dilatation
In general, the CBD should measure 7 mm
or less in healthy patients, although the normal duct may be dilated in older patients and
those who have undergone cholecystectomy.
Thus, overemphasizing CBD measurements,
especially when the ducts are only mildly dilated, should be avoided, particularly in patients without symptoms (i.e., biliary colic,
right upper quadrant pain, jaundice) or biochemical markers suggestive of biliary obstruction [2]. In patients with borderline enlargement of the ducts without CT evidence
of a discrete obstructing mass or other suspicious imaging features, the best course of
action may be to simply recommend correlation with clinical and biochemical markers of obstruction rather than recommending
MRCP or ERCP in every patient.
Normal bile ducts on CT should have an
almost imperceptible wall ( 1 mm), with
only minimal enhancement on either arteri-

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Raman and Fishman

al or venous phase images. In the setting of
dilated bile ducts, the ducts must be carefully
evaluated for the presence of focal or diffuse
hyperenhancement on arterial or venous phase
images; delayed enhancement, if delayed images are acquired; focal or diffuse bile duct
wall thickening; and a discrete mass.
The same precepts traditionally used to
analyze the bile ducts on ERCP are just as
important to apply to CT as well: The CBD
should be carefully evaluated for discrete
sites of transition between dilated proximal
ducts and a decompressed or narrowed distal duct. Once a site of transition is found,
any evidence of irregularity, abrupt narrowing, or shouldering at the transition point
should raise suspicion for malignancy. Although this evaluation can be performed
using the source axial images, the use of
coronal and sagittal MPR images and 3D reconstructions can be vital [3].
Technique
In any patient with a suspected pancreatobiliary abnormality, a dual-phase study with
both arterial and venous phase images should
be acquired. The arterial phase images are used
to identify hypervascular tumors (i.e., ampullary carcinoid, pancreatic neuroendocrine tumors, hypervascular gastrointestinal stromal
tumors), subtle biliary tree mucosal hyperenhancement and thickening, and tumor neovascularity and to evaluate the arterial anatomy
before surgery. The venous phase images are
used to evaluate the liver and pancreas for traditionally hypovascular tumors and metastases, locoregional lymphadenopathy, and involvement of the venous vasculature by tumor
[4]. Although delayed images are not routinely
acquired, they may be added to the protocol if
cholangiocarcinoma is prospectively thought
to be a diagnostic consideration.
Positive oral contrast material absolutely
must be avoided in patients presenting with
jaundice or a suspected mass in the pancreas, ampulla, or duodenum: Not only will the
positive contrast agent obscure any intraluminal mass in the duodenum or near the ampulla, but also streak artifact from the contrast agent will make evaluation of subtle
duodenal wall thickening or hyperenhancement near the ampulla difficult to perceive
and can interfere with 3D postprocessing algorithms. Instead, a neutral contrast agent
such as water or a barium suspension (VoLumen, Bracco Diagnostics) should be used,
and some portion of this contrast medium
should be given to the patient immediately

18

before scanning to maximize gastric and duodenal distention [4].

After the acquisition of source axial images and reconstruction of standard MPRs, we
have found three image postprocessing reconstruction algorithms (including 3D postprocessing) to be the most useful for image
interpretation: volume rendering (VR), minimum intensity projections, and curved planar reformations. VR is a complex, computationally intensive computer algorithm that
assigns a specific color and transparency to
each voxel in a dataset on the basis of its attenuation and relationship to other adjacent
voxels before presenting these data in a 3D
display. The VR technique allows the best
soft-tissue definition of any of the 3D reconstruction tools and is a vital component
of biliary analysis. This technique is useful
not only for increasing the conspicuity of obstructing lesions, but also for increasing the
conspicuity of subtle biliary hyperenhancement and thickening [4, 5].
Minimum-intensity-projection reconstructions rely on the same principles as maximum-intensity-projection (MIP) imaging.
However, unlike MIP reconstructions, which
project the highest-attenuation voxels in a dataset, minimum-intensity-projection reconstructions project the lowest-attenuation voxels, making them extraordinarily valuable for
visualization of fluid-filled structures, such as
the biliary tree or pancreatic duct, particularly
when these structures are dilated or obstructed. At our institution, although MIP images
are not a major component of biliary tree 3D
analysis, minimum-intensity-projection reconstructions are performed in every case, and
we have experienced great success in identifying small tumors that were more conspicuous
when using this imaging technique [6, 7].
Finally, given that the entire extrahepatic
bile duct does not normally course in the coronal, sagittal, or axial plane, visualizing the
entire duct on any given MPR or the source
axial images can be impossible, making it
more difficult to perceive sites of subtle wall
thickening or even a discrete mass. Curved
planar reformations, which are interactively
created by the user as he or she identifies the
course of the duct, allow the entire CBD to
be displayed in a single 2D image and are
part of our routine evaluation [6, 8].
Differential Diagnosis
Malignant Causes
Ampullary adenomaAdenomas of the
small bowel are relatively uncommon com-

pared with those of the large bowel, and

within the small bowel, adenomas are more
common in the ileum and jejunum than in
the duodenum. Within the duodenum, 10%
of all duodenal polyps are ultimately found
to be adenomas, and the most common location is in proximity to the ampulla of Vater
[9]. These lesions are most common in elderly patients, and other than familial adenomatosis coli, no other clear risk factors for the
development of ampullary adenomas have
been described in the literature [9].
Ampullary adenomas are benign lesions
that retain malignant potential: Similar to
the adenoma-carcinoma sequence in the colon, these lesions usually contain foci of lowgrade dysplasia and have the potential to develop higher-grade dysplasia and invasive
carcinoma, particularly as they grow larger.
Up to 60% of ampullary adenomas are ultimately found to harbor at least some foci
of invasive carcinoma (especially in large
lesions), so the preoperative distinction between an adenoma and an ampullary carcinoma is not relevant for the radiologist [9].
There are no dedicated descriptions of the
imaging appearance of ampullary adenomas
in the literature to date; in our experience,
although ampullary adenomas may have a
slightly lesser predilection for causing severe
ductal obstruction, their CT appearance is
not significantly different from that of ampullary carcinomas (Figs. 1 and 2).
CholangiocarcinomaAlthough cholangio
carcinomas of the extrahepatic duct have
a strong predilection for the proximal one
third of the duct, up to 20% of lesions occur in the distal one third and 95% of patients show ductal obstruction at the time
of diagnosis [10]. Traditionally, both intrahepatic and extrahepatic cholangiocarcinomas have been classified into three different
morphologic subtypes, each of which presents with a different appearance on imaging:
mass-forming cholangiocarcinoma, periductal infiltrating cholangiocarcinoma, and intraductal cholangiocarcinoma.
The mass-forming cholangiocarcinoma
is the easiest of the three subtypes to diagnose: It usually presents as a discrete mass
or nodule that obstructs the extrahepatic bile
duct. This mass does not have to be particularly large to obstruct the duct, and both
the source axial images and coronal MPRs
should be scrutinized for evidence of a discrete nodule. Like intrahepatic cholangiocarcinoma, these lesions can show some hypervascularity on arterial phase images and

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CT of the Distal CBD and Ampulla

increased enhancement on delayed images,
making multiphase protocols extremely useful for diagnosis [10, 11].
The periductal infiltrating variant can be
more difficult to identify; it often presents as
asymmetric bile duct wall thickening and enhancement at the site of transition in the dilated biliary tree and usually involves only a
short segment. These tumors can rarely involve a larger segment of the bile duct, sometimes extending into the intrahepatic biliary
tree, and can rarely be mistaken for an inflammatory process. In our experience, volume-rendered 3D images have proven to be
extremely useful in identifying this variant
of cholangiocarcinoma because they nicely
accentuate sites of abnormal enhancement
and thickening [10] (Figs. 35).
Finally, the intraductal variant is quite
rare and can have a variable morphology that
is not readily distinguishable from the other two morphologic subtypes on CT. These
lesions tend to spread along the inner surface of the bile duct, either as a superficially spreading mass that presents as focal wall
thickening or as a discrete intraluminal polyploid mass [10].
Ampullary carcinomaAlthough radiologists often regard the ampulla as a single
anatomic entity, it is actually a region composed of multiple different structures, the
most important of which are the distal CBD,
downstream pancreatic duct, and duodenum.
Accordingly, this region is composed of several different types of epithelium, including
intestinal epithelium (duodenum), foveolarlike mucosa (papilla of Vater), and pancreatobiliary epithelium (distal CBD and pancreatic duct) [12]. As a result, even though
ampullary carcinomas are often thought of
as a single pathologic entity, in reality they
represent a heterogeneous group of tumors
arising in the region of the ampulla that can
have different biologic behaviors depending
on their exact origin. In general, pathologists broadly divide these tumors into three
groups: tumors arising from the duodenal
epithelium of the ampulla, tumors arising
from the pancreatobiliary epithelium of the
distal CBD or pancreatic duct, and intraampullary tumors showing histologic overlap
with combined duodenal and pancreaticobiliary epithelial morphology.
These three tumor types can have very
different prognoses and biologic behavior.
Intraampullary tumors tend to have the best
prognosis, which may result from their origin within the ampulla and relatively earlier

presentation because of a greater propensity for early, severe ductal obstruction and a
lesser invasive component. Alternatively, tumors arising from the pancreatobiliary epithelium tend to have a worse prognosis, with
both histology and prognosis relatively similar to pancreatic adenocarcinoma. Finally,
tumors arising from the duodenal mucosa
tend to be large at presentation with a greater propensity for lymph node metastases but
with a prognosis roughly comparable to duodenal adenocarcinoma [12].
Regardless of this pathologic distinction,
these three subtypes cannot be reliably distinguished on any imaging modality including CT. Kim et al. [13] reported that ampullary carcinomas obstructed both the pancreatic
and biliary ducts in 52% of cases and that
48% of cases showed only biliary ductal dilatation. These results likely reflect the different possible sites of origin for these tumors in
the region of the ampulla and are concordant
with our experience, which is that isolated
dilatation of the pancreatic duct alone is extraordinarily rare. The lesion can appear as a
discrete nodular mass or as ill-defined softtissue thickening near the ampulla. However,
in our experience, even if a discrete mass or
lesion is not perceptible, careful examination
of the ampulla on coronal MPR or 3D images will often show an abrupt margin or irregularity at the site of transition in the CBD,
which should definitely precipitate further
evaluation with ERCP [1315] (Figs. 610).
Ampullary carcinoidAlthough ampullary carcinoid tumors are rare, with fewer than
120 cases described in the literature, these
neoplasms have an imaging appearance that
may allow a more specific diagnosis [16]. Interestingly, ampullary carcinoids are thought
to be biologically distinct from other smallbowel or duodenal carcinoid tumors, with
ampullary carcinoids showing a higher predilection for metastatic disease [17]. These
tumors tend to present as small lesions, can
develop nodal disease even when the primary tumor is quite small, and almost never
present with a hypersecretion syndrome [17].
Given the risk of aggressive behavior even
with small lesions and their tendency to obstruct the biliary tree, these tumors invariably
are treated with a pancreaticoduodenectomy
(Whipple procedure) [18].
Like carcinoid and neuroendocrine tumors elsewhere in the bowel or the pancreas, ampullary carcinoid tumors (and their locoregional lymph node metastases) tend to
be avidly enhancing on arterial phase imag-

es (Fig. 11). Although the exact site of origin

of the tumor may be in doubt, the presence of
biliary and pancreatic ductal dilatation and a
clear fat plane between the mass and the adjacent pancreatic head should allow the radiologist to prospectively suggest that the tumor
arises from the ampulla rather than the pancreatic head or the adjacent duodenal wall.
Pancreatic adenocarcinomaIn some
cases, differentiation of a primary pancreatic head or uncinate process adenocarcinoma from a primary ampullary neoplasm may
be difficult: Both types of lesions can result
in biliary and pancreatic ductal obstruction;
both tend to be hypoenhancing relative to the
normal pancreatic parenchyma; and the exact site of origin of a lesion may not be immediately evident, particularly with pancreatic adenocarcinomas primarily centered in
the pancreaticoduodenal groove (an anatomic space that includes the ampulla) [4, 19].
However, the distinction between the two
types of lesions may not be important given
that both are treated with pancreaticoduodenectomy. In our experience, primary ampullary lesions, despite their involvement of the
pancreatic duct, do not commonly result in
upstream pancreatic atrophy, as is often the
case with pancreatic adenocarcinoma (Figs.
1214). Moreover, in some cases, a careful
appraisal of the images, particularly in the
coronal plane, may allow the radiologist to
suggest that the lesion is centered in the pancreatic head rather than the ampulla.
Periampullary duodenal carcinomaThe
duodenum and proximal jejunum are the most
common sites for the development of smallbowel adenocarcinoma, accounting for 50
70% of lesions [19]. When these tumors arise
in close proximity to the ampulla, ultimately
resulting in biliary and pancreatic ductal obstruction, the distinction between a primary periampullary duodenal adenocarcinoma
and a primary ampullary carcinoma is impossible to make based on imaging alone (Fig.
15). Once again, although these lesions arise
in very close anatomic proximity, their biologic behavior tends to be different: Adsay et
al. [12] reported that duodenal adenocarcinomas were usually less advanced at presentation (i.e., lesser T stage and less likely to harbor lymph node metastases) than ampullary
tumors and that patients with duodenal adenocarcinomas typically had better survival rates.
Benign Causes
Distal common bile duct stonesThere
is little argument that CT is not the prima-

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Raman and Fishman

ry diagnostic modality for the identification
of stones within either the extrahepatic bile
duct or the gallbladder, with both ultrasound
and MRI holding clear advantages over CT
in both sensitivity and specificity [6]. However, the poor reputation of CT in evaluating
biliary stones has almost certainly been exaggerated by a number of early studies based on
older technology that were marred by motion
artifact, thick-section acquisitions, and poor
spatial and contrast resolution [6]. Depending
on their internal composition, stones can be
visualized to varying degrees on CT: Highly
calcified gallstones can usually be fairly easily identified, often with a rim or crescent
of surrounding bile, whereas soft-tissuedensity stones can be more difficult to visualize
[20] (Fig. 16). Thus, visualization of cholesterol stones, which are often isodense to surrounding bile, is particularly problematic on
CT. Moreover, small stones of soft-tissue
density, particularly when impacted at the
level of the ampulla, can be almost impossible to identify in some cases [21].
As a result, the radiologist must attempt
to carefully examine the distal CBD in the
setting of biliary obstruction and dilatation,
particularly in patients with a known history of cholecystectomy or gallstones. The use
of narrow window settings is vital for identifying subtle soft-tissuedensity stones and
the use of multiplanar and curved planar reformations is helpful for tracing the extrahepatic bile duct inferiorly from the liver hilum
to the ampulla [21]. Even if a high-density
stone is not identified, a sharp cutoff of a dilated CBD at the ampulla, often with a wellmarginated meniscus configuration, can
hint at the presence of an occult stone [21].
Using these primary and secondary signs
of choledocholithiasis, several studies have
shown CT sensitivities of more than 80%,
including at least one study predating the
MDCT era [2124] (Figs. 17 and 18).
Some practices use unenhanced images in
the belief that unenhanced imaging might increase the conspicuity of high-density stones
in the duct, but there are no data to suggest
that dedicated unenhanced images provide
any significant benefit in stone detection.
Although not widely used in routine clinical practice, CT examinations performed
at higher tube voltage settings (usually 140
kVp) may increase the conspicuity of stones
and, in particular, may increase the attenuation and conspicuity of cholesterol stones
that are difficult to perceive on standard images [25, 26]. This increased conspicuity of

20

stones at higher tube voltage settings may offer a source of potential clinical utility for
dual-energy CT as this technology becomes
more widely used in practice.
Benign biliary stricturesThe list of different causes of benign biliary strictures is
long and extensive, with the most common
causes including prior iatrogenic injuries
(most often after cholecystectomy and liver transplantation), chronic pancreatitis, and
primary sclerosing cholangitis (PSC). Other
more rare causes include HIV cholangiopathy, unusual infections (including tuberculosis) (Fig. 19), Mirizzi syndrome, inflammatory strictures from certain chemotherapy drugs
and other medications, radiation therapy, portal biliopathy, and sarcoidosis [2729]. Although a detailed discussion of each of these
entities is beyond the scope of this article, certain entities are important to consider when
dealing with obstruction of the distal CBD,
including chronic pancreatitis, PSC, and strictures related to HIV cholangiopathy [30].
Chronic pancreatitis can be associated
with distal bile duct strictures in up to 46% of
patients and jaundice in up to 50% [27]. The
presence of stigmata of chronic pancreatitisincluding pancreatic ductal irregularity
and beading, parenchymal and ductal calcification, pancreatic pseudocysts, and pancreatic atrophyin the setting of pancreatic and
biliary ductal dilatation should strongly raise
the possibility of this diagnosis [27]. However, given that patients with chronic pancreatitis are at increased risk of developing pancreatic cancer and the fact that some patients
can develop a fibroinflammatory mass at the
pancreatic head, the distinction between benign and malignant strictures at this site may
not be a simple one [3133].
PSC very rarely involves the extrahepatic bile duct without abnormalities of the intrahepatic ducts. As a result, when considering this diagnosis in a patient with a CBD
stricture, it is imperative to closely evaluate
the intrahepatic ducts for characteristic features, including beading of the ducts and alternating sites of ductal narrowing and dilatation. Like other types of cholangitis, PSC
can be associated with ductal thickening and
enhancement, which is usually more diffuse
than is commonly seen with malignancy [27]
(Fig. 20). However, even in patients with
known PSC, abnormal ductal enhancement,
thickening, or strictures cannot automatically
be assumed to be inflammatory given that the
lifetime risk of cholangiocarcinoma in PSC
patients may be as high as 1030% and up to

0.6% per year [34, 35]. Any new stricture on

CT regardless of its appearance or apparently
benign features must be considered as suspicious and further examined for the presence
of malignancy. In particular, CT has proven
efficacy in identifying cholangiocarcinoma
in the setting of PSC with a sensitivity of 82%
and specificity of 80%, which are higher than
standard cholangiography [36].
Now increasingly rare given the widespread availability of highly active antiretroviral therapy (HAART), HIV cholangiopathy can result in strictures of both the
intrahepatic and extrahepatic ducts and in
papillary stenosis. Depending on the exact
findings, HIV cholangiopathy can mimic the
appearance of an obstructing CBD cholangiocarcinoma, ampullary neoplasm, or inflammatory cholangitis such as PSC [27, 30].
Imaging alone cannot reliably differentiate
a benign from a malignant biliary stricture,
although benign strictures are less likely to
produce severe proximal biliary dilatation,
are usually associated with a lesser degree of
bile duct wall thickening and enhancement at
the site of transition, and should not be associated with suspicious locoregional lymphadenopathy or metastatic disease [27]. Moreover,
although it can be difficult in many cases, a
careful examination of the site of transition
in the distal CBD should reveal smooth, tapered narrowing rather than an abrupt margin or shouldering [2].
Conclusion
In our experience, both the distal CBD
and the ampulla are common sites of missed
diagnoses for radiologists. Avoiding mistakes in interpreting imaging findings in this
location requires a systematic approach especially in the setting of unexplained biliary
ductal dilatation. Rather than simply suggesting that MRCP or ERCP be performed
for the ultimate diagnosis, radiologists can
perform a careful CT evaluation using multiplanar reformations and 3D imaging to determine the correct diagnosis prospectively.
A timely and correct diagnosis is imperative
because lesions in the ampulla and CBD can
be very aggressive despite their small size.
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34. Morris-Stiff G, Bhati C, Olliff S, et al. Cholangiocarcinoma complicating primary sclerosing cholangitis: a 24-year experience. Dig Surg 2008;
25:126132
35. Schulick RD. Primary sclerosing cholangitis: detection of cancer in strictures. J Gastrointest Surg
2008; 12:420422
36. Campbell WL, Peterson MS, Federle MP, et al.
Using CT and cholangiography to diagnose biliary tract carcinoma complicating primary sclerosing cholangitis. AJR 2001; 177:10951100
(Figures start on next page)

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Raman and Fishman

Fig. 175-year-old man with ampullary mass found at upper endoscopy performed for symptoms of indigestion and reflux.
A and B, Coronal multiplanar reformation (A) and volume-rendered (B) CT images show discrete mass at ampulla (arrow, A) and only minimal biliary ductal dilatation (B).
Mass was ultimately found to be ampullary adenoma.

Fig. 270-year-old woman with ampullary mass found at endoscopy performed for sensation of chest fullness.
A and B, Coronal multiplanar reformation (A) and coronal volume-rendered (B) CT images show polyploid mass (arrows) in periampullary
duodenum and no visible ductal dilatation. Mass was found to be ampullary adenoma.

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CT of the Distal CBD and Ampulla

A
Fig. 375-year-old woman who presented with 1-year history of recurrent jaundice.
A and B, Coronal volume-rendered CT images show abrupt irregular narrowing and beaking of distal common bile duct (CBD) with irregular
enhancement (arrows). This case was found to be distal CBD cholangiocarcinoma.

Fig. 475-year-old man who presented with elevated liver enzyme values and
bilirubin level during routine office visit. Coronal multiplanar reformation CT image
shows focal soft tissue (arrow) obstructing mid common bile duct with proximal
biliary dilatation and abrupt margin at site of transition. This case was found to be
cholangiocarcinoma.

Fig. 560-year-old man who presented with elevated liver function test values
and abdominal pain. Coronal multiplanar reformation CT image shows diffuse
enhancement and wall thickening (arrow) of common bile duct. Intrahepatic ducts
(not shown) were not involved. Although inflammatory or infectious cholangitis
was considered, this case was found to be cholangiocarcinoma.

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Raman and Fishman

Fig. 651-year-old woman who presented with

weight loss, jaundice, and abdominal pain. Coronal
volume-rendered CT image shows markedly dilated
intrahepatic and extrahepatic ducts and abrupt
beaking (arrow) and narrowing of distal common
bile duct. Although no discrete mass was visualized
on CT, small ampullary carcinoma was found at
endoscopic ultrasound.

Fig. 753-year-old man who presented with painless

jaundice. Coronal multiplanar reformation CT image
shows polyploid mass (arrow) at ampulla obstructing
both pancreatic duct and common bile duct. This
mass was found to be ampullary carcinoma.

Fig. 869-year-old man who presented with jaundice and pruritus.

A and B, Coronal volume-rendered (A) and multiplanar reformation (B) CT images. Despite presence of stent and poor duodenal distention,
images show focal medial duodenal wall thickening (arrows) at level of ampulla, which was ultimately found to be ampullary carcinoma.

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CT of the Distal CBD and Ampulla

Fig. 1067-year-old man who presented with jaundice. Coronal volumerendered CT image shows focal mass (arrow) at ampulla obstructing distal
common bile duct (CBD). Distal CBD is abruptly narrowed and irregular. This
mass was ultimately found to be ampullary carcinoma.

Fig. 969-year-old woman who presented with jaundice and abdominal pain.
Coronal volume-rendered CT image shows focal wall thickening (arrows) along
medial duodenal wall at level of ampulla, which was ultimately found to be
ampullary carcinoma.

Fig. 1149-year-old woman with incidentally discovered biliary dilatation on unenhanced CT performed to exclude renal stones.
A and B, Axial (A) and coronal (B) arterial phase multiplanar reformation images show hypervascular mass (white arrows) obstructing distal common bile duct and
pancreatic ducts and adjacent hypervascular lymph node metastasis (black arrow, B). Mass was found to be ampullary carcinoid.

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Raman and Fishman

Fig. 1278-year-old man who presented with jaundice.

A and B, Coronal multiplanar reformation (MPR) (A) and volume-rendered (B) CT images show abrupt obstruction of common bile duct by hypodense mass in pancreatic
head (arrows).
C, Coronal MPR image shows concurrent severe obstruction of pancreatic duct. Mass was found to be pancreatic adenocarcinoma.

Fig. 1346-year-old woman who presented with

painless jaundice. Coronal minimum-intensityprojection CT image shows markedly dilated common
bile duct with abrupt narrowing near ampulla.
Morphology of ductal narrowing raised concern even
though no discrete mass was identified; this case
was found to be small pancreatic adenocarcinoma
obstructing duct.

26

Fig. 1475-year-old man who presented with

jaundice and abdominal pain. Coronal volumerendered CT image shows markedly dilated common
bile duct with abrupt irregular narrowing distally.
Subtle texture change in pancreatic head is seen but
no discrete mass. This case was found to be small
pancreatic adenocarcinoma.

Fig. 1571-year-old man with duodenal mass

discovered during upper endoscopy performed for
upper gastrointestinal bleeding. Coronal multiplanar
reformation CT image shows annular constricting
mass (arrows) that extends into ampulla. This
mass was judged after surgical resection to be
periampullary duodenal adenocarcinoma.

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CT of the Distal CBD and Ampulla

Fig. 1676-year-old man with known cholelithiasis

on prior ultrasound. Axial CT image shows softtissuedensity stone (arrow) in distal common
bile duct and ampulla with characteristic rim of
surrounding bile.

Fig. 1784-year-old man with history of gallstones.

Coronal volume-rendered CT image shows
obstructing stone (arrow) in distal common bile duct
and proximal biliary dilatation.

Fig. 1891-year-old woman with choledocholithiasis

incidentally discovered during evaluation for
melanoma. Coronal volume-rendered CT image
shows common bile duct stone (arrow) without
significant proximal biliary dilatation.

Fig. 1978-year-old woman who presented with fever and jaundice. Coronal
volume-rendered CT image shows focal thickening of distal common bile duct
(arrows) initially thought to be either pancreatic cancer or ampullary carcinoma.
This case was ultimately found to be tuberculosis, and there were multiple other
sites of infection elsewhere in body.

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Raman and Fishman

Fig. 2030-year-old man with known primary sclerosing cholangitis.

A and B, Axial (A) and coronal (B) CT images show thickening and enhancement of right hepatic duct (arrow, A) and common bile duct (arrow, B); these
findings are suggestive of active bile duct inflammation.

F O R YO U R I N F O R M AT I O N

This article is available for CME and Self-Assessment (SA-CME) credit that satisfies Part II requirements for
maintenance of certification (MOC). To access the examination for this article, follow the prompts associated with
the online version of the article.

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