Clinical Significance and Resource Burden of Double Duct Sign in Non-jaundiced Patients.

Aim The study aims to determine the incidence of malignancy at presentation and subsequent risk of malignancy (at 12 months follow-up) in a cohort of patients with double duct sign (DDS) on cross-sectional imaging but no visible stigmata of jaundice. The study also correlates malignancy with liver enzyme dysfunction and estimates the resource burden incurred during the investigation of these patients. Methods A search for the key term "double duct sign" was undertaken in the radiological database of a tertiary hepatopancreatobiliary (HPB) centre between March 2017 and March 2022. Radiological reports, clinic letters, blood results, and multidisciplinary team meeting (MDT) outcomes were reviewed during this period and at one year. The national tariff payment system was reviewed to identify tariffs for different investigations required for the cohort and to calculate the total cost incurred. Results Ninety-seven patients with DDS were identified. Sixty-four patients (66%) had a normal bilirubin (0-21 µmol/L) at presentation and were included in the analysis. Seven patients (10.9%) were diagnosed with malignant peri-ampullary tumours, and 21 (32.8%) were diagnosed with benign diseases. In 34 patients (53%) with DDS, the underlying cause remained uncharacterised. Most patients had mild abnormalities of liver enzymes, but two patients (4.3%) were diagnosed with malignant peri-ampullary tumours despite having normal serological values. Patients who had a benign diagnosis and/or who had cancer excluded without a definitive diagnosis did not go on to develop a malignancy at 12 months follow-up. However, in those patients where the underlying aetiology could not be characterised, extended surveillance was required with a total of 80 MDT discussions and multiple surveillance scans (103 CT and 65 MRI scans). Twenty-six patients underwent endoscopic ultrasound (EUS) with three patients requiring more than one EUS examination (29 investigations in total). The cost of these investigations was £38,926.89. Conclusion This study confirms that DDS even in patients without clinical jaundice or with normal liver enzymes requires careful investigation to exclude malignancy despite the resource burden this entails. This supports previously reported results in the literature, and despite the increased use of cross-sectional imaging, DDS remains a clinically significant finding. Large cohort risk stratification studies would be useful to determine clinical urgency and allow the appropriate allocation of resources.

The Diagnostic Yield of Endoscopic Ultrasound in Asymptomatic Patients with Unexplained Dilated Common Bile Duct, or Double Duct Sign with Normal Transaminase a Retrospective Study from a Single Urban-based University Endoscopy Center.

Background: Common bile duct dilatation alone or double duct sign (both CBD and dilated pancreatic duct dilatation) and abnormal liver enzymes are highly predictive of biliary disease. This can be identified on ultrasound (US), CT scan, and/or magnetic resonance cholangiopancreatography (MRCP). Unexplained dilatation on imaging might warrant endoscopic ultrasound (EUS) to identify any occult causes. Supporting literature about the importance of using EUS in these conditions is evolving with no clear evidence-based approach to evaluate asymptomatic dilated ducts.We aim to investigate the diagnostic yield of EUS in unexplained CBD dilatation or double duct sign with normal liver enzymes. Method: A retrospective data analysis was conducted from January 2015 to October 2021 on asymptomatic patients with a dilatated CBD of 7 mm or more and 9 mm if the patient had a cholecystectomy history or double duct sign with normal liver enzymes. Result: 32 EUS procedures were indicated for unexplained dilated CBD or double duct sign on imaging with normal liver enzymes. 23 had CBD dilatation alone (72 %), and 9 had a double duct sign (28 %). 20 of the included patients were females (63 %), and 12 were males (37 %), with a mean age of 63.8 ± 17 and 68.2 ± 14 years old, respectively (p = 0.424). The diagnosis after EUS in CBD dilatation alone showed a yield of 56 % as follow; no pathology in 10 (44 %), sludge in 9 patients (39 %), CBD stone in 3 (13 %), malignant stricture in 1 (4 %) (Fig. 1). On the other hand, EUS in those with double duct signs showed a diagnostic yield of 55 %; no pathology in 4 (45 %), pancreatic head adenocarcinoma in 3 patients (33 %), Biliary stone in one patient, and malignant CBD stricture in one patient (11 % each) (Fig. 2). Conclusion: Unexplained CBD dilatation or Double duct sign on imagining in patients with normal liver enzymes should warrant further investigation with EUS to avoid missing serious pathological conditions such as stones, sludge, stricture, or a mass.

Incidental double duct sign: Should we be worried? Results from a long-term follow-up study.

Backgrounds/Aims: Double duct sign (DDS) (dilated common bile and pancreatic duct) is synonymous with pancreatic head/peri-ampullary tumor (PHPAT). There is limited evidence on whether incidental DDS (I-DDS) is associated with an increased risk of malignancy. This study aimed to evaluate 5-year outcomes of I-DDS. Methods: Patients were categorized according to their risk of malignancy. 'Low-risk' patients, including those with I-DDS between 2010 and 2015, were analyzed in this study. The primary outcome was incidence of PHPAT within five years of identification of DDS. Histology results from endoscopic ultrasound-guided biopsy were considered diagnostic. Secondary outcomes were incidence of benign causes, extent of follow-up investigations, and clinical indicators of malignancy in patients with DDS. Results: Among 103 patients with DDS, 20 had I-DDS. Subsequent follow-up of these 20 patients found no patient with PHPAT, two (10%) patients with chronic pancreatitis, and 18 (90%) patients with no cause found. The median follow-up duration for 'low-risk' patients was 7.3 years (range, 6-11 years). The mean number of follow-up investigations per patient was two (range, 0-9). Investigations included computed tomography (n = 27), magnetic resonance cholangiopancreatography (n = 23), endoscopy (n = 16), and ultrasound (n = 14). Patients with jaundice were more likely to have malignancy (p < 0.01). Those with abdominal pain were more likely to have a benign cause (p < 0.01). Hyperbilirubinemia and/or deranged liver enzymes and raised CA19-9 were more likely to be associated with PHPAT (p < 0.01). Conclusions: Patients with I-DDS have a low risk of developing PHPAT within five years.

Neuroendocrine Tumor of the Ampulla of Vater: A Case Report.

Neuroendocrine tumors (NETs) of the ampulla of Vater are extremely rare. Here, we discuss the clinical presentation, diagnostic challenges, and treatment options of a recently experienced case of NET of the ampulla of Vater in light of the literature. A 56-year-old woman presented with recurrent upper abdominal pain. Ultrasonography (USG) of the whole abdomen showed multiple gallstones along with a dilated common bile duct (CBD). For evaluating the dilated CBD, a magnetic resonance cholangiopancreatography was performed, which revealed the double-duct sign. Subsequently, an upper gastrointestinal endoscopy showed a bulged-out ampulla of the Vater. Biopsy and histopathological examination of the growth yielded the diagnosis of adenocarcinoma. A Whipple procedure was performed. Macroscopically, a 2 cm growth was noted involving the ampulla of Vater, and microscopic findings were consistent with a well-differentiated NET, grade 1 (low grade). The diagnosis was further confirmed by immunohistochemical staining (pan-cytokeratin positive, synaptophysin positive, and focally chromogranin positive). Her postoperative course was uneventful except for delayed gastric emptying. A detailed evaluation and a high index of suspicion are required for the diagnosis of this rare tumor. Treatment is relatively easier after a proper diagnosis.

Recurrent Pancreatic Pseudocysts Due to Alcohol-Related Chronic Pancreatitis With Double-Duct Sign and Spontaneous Rupture.

A 36-year-old female presented with recurrent attacks of alcohol-related acute on chronic pancreatitis complicated by a pancreatic pseudocyst in the head of the pancreas. The cyst was causing obstruction of the common bile duct (CBD) and pancreatic duct (PD) on magnetic resonance cholangiopancreatography (MRCP). She underwent endoscopic ultrasound (EUS)-guided aspiration of the cyst to dryness. A few months later, she presented with epigastric pain and jaundice. MRI pancreas and MRCP revealed a pancreatic cyst in the head of the pancreas, which had grown in size, compressing the CBD and PD with extra and intrahepatic biliary dilatation. There was a recurrence of a new lobulated peripancreatic pseudocyst, which had ruptured resulting in a large collection compressing the right renal capsule. Percutaneous drainage of the ruptured pseudocyst was performed, followed by endoscopic retrograde cholangiopancreatography (ERCP) that revealed distal CBD stricture, which was stented. Her symptoms improved and she was discharged with no further recurrences of obstructive jaundice during the one-year follow-up period.

Biliary type-II sphincter of Oddi dysfunction with a pancreatic duct dilation: a case report and review of the literature.

BACKGROUND: The double-duct sign is defined as dilation of both the common bile duct and pancreatic duct, which usually indicates pancreatic malignancy. However, benign causes have also been reported to cause a double-duct sign. CASE PRESENTATION: We present the case of a 59-year-old Caucasian female patient admitted to the Gastroenterology Department with intermittent right epigastric abdominal pain and an intact gallbladder. A double-duct sign was seen on endoscopic ultrasound. The suspicion of pancreatic malignancy was excluded through follow-up investigations. Biliary type II sphincter of Oddi dysfunction was diagnosed with an association of the double-duct sign. Sphincterotomy was performed to reduce pain, and there was no recurrence of symptoms during follow-up. CONCLUSIONS: This is the third reported case in the literature of the double-duct sign associated with sphincter of Oddi dysfunction. This case emphasizes that the double-duct sign is not always caused by a local malignancy. The literature review of the reported cases has been summarized to help in the diagnosis of future similar cases.

Diagnostic performance of EUS in non-jaundiced patients with an incidental finding of double duct sign on cross-sectional imaging: A systematic review and meta-analysis.

BACKGROUND/OBJECTIVES: Dilatation of the pancreatic duct and common bile duct, known as double duct sign (DDS), suggests sinister pathology at the periampullary region. Non-jaundiced patients with incidental DDS and otherwise normal cross-sectional imaging present a diagnostic dilemma to the multidisciplinary team (MDT). The primary aim of this review was to assess the diagnostic yield of endoscopic ultrasound (EUS) in detecting causal pathology in this patient population. METHODS: A systematic literature search (Medline, EMBASE, Google Scholar, Cochrane database and PROSPERO) was performed to identify original studies that reported EUS findings in patients with incidental DDS. Primary outcome was detection of a periampullary tumour. Secondary outcome was detection of benign causal pathology. Meta-analysis was used to calculate an absolute measure (pooled proportion) of pathology detection. RESULTS: Four studies (177 patients) were included. EUS detection rate for a periampullary tumour was 5% (95% CI, 0-10%) including both adenocarcinomas and adenomas. EUS detection rate for benign causal pathology was 22% (95% CI, 10-34%), the most common being chronic pancreatitis CONCLUSION: Non-jaundiced patients with incidental DDS on cross-sectional imaging have a 5% risk of a periampullary tumour that can be detected by EUS.

Simultaneous Courvoisier's and double duct signs.

Presence of Courvoisier's or double duct signs in a jaundiced patient is suggestive of malignant obstruction of the pancreaticobiliary ductal system. The oncologic impact of the simultaneous occurrence of these signs on the survival of patients with periampullary cancer is unknown. We report a case of obstructive jaundice secondary to an ampullary cancer demonstrating the Courvoisier's sign on clinical examination and a double duct sign on imaging. The patient underwent a pancreaticoduodenectomy which confirmed an ampullary adenocarcinoma.

Parotid gland with double duct: an anatomic variation description / Glándula parótida con doble conducto: descripción de una variación anatómica

The parotid is the largest salivary gland in humans producing an essentially serous secretion, which normally reaches the oral cavity through a sole duct (the parotid duct) after the latter making its way through the buccinator muscle to reach the mucosa lining the mouth at the level of the cheek. The present study reports on a rare case of double parotid duct found during the dissection the right side of the face of a cadaver of a 46-year-old male individual. The superior (Dl) and inferior (D2) ducts were 26.49 mm and 37.25 mm long, respectively. Based on the diameter of both ducts (Dl and D2) taken in the posterior (3.05 mm and 2.84 mm, respectively) and mid (2.84 mm and 2.68 mm, respectively) thirds, as well as on the histological findings, both ducts were considered to be main parotid ducts. These two ducts merged at the level of the anterior third forming one sole opening into the oral cavity. The data hereby reported are relevant to the various clinical and surgical procedures involving the parotid gland.

La parótida es la glándula salival más grande presente en el hombre y su producto de secreción, básicamente seroso, es normalmente dirigido hasta la cavidad oral, a través de un único canal parotídeo que, luego de perforar el músculo buccinador, desemboca en la mucosa de la mejilla. Este trabajo muestra un caso raro de doble canal parotídeo hallado durante la diseccción de un cadáver de sexo masculino, de 46 años de edad, en el lado derecho del rostro. Los canales superior (DI) e inferior (D2), presentaron una longitud de 26,49 mm y 37,25 mm, respectivamente. En base a los diámetros presentados por los canales en los tercios posterior (DI 3,05mm; D2 2,84 mm) y medio (DI 2,84mm; D2 2,68 mm) y de acuerdo con los hallazgos histológicos, ambos fueron considerados principales. En el tercio más anterior los canales se fusionaron, presentando una única apertura en la cavidad oral. Las informaciones presentadas en este documento son relevantes para diferentes procedimientos clínicos y quirúrgicos que tengan relación con la glándula parótida.