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

Gastrointestinal Imaging
Review
Abnormalities of the Distal
Common Bile Duct and Ampulla:
Diagnostic Approach and
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Differential Diagnosis Using

FOCUS ON:

Multiplanar Reformations and

3D Imaging
Siva P. Raman1 OBJECTIVE. The distal common bile duct (CBD) and ampulla are extremely difficult
Elliot K. Fishman sites to evaluate on CT. This article seeks to provide the reader with a framework and algo-
rithmic approach to the evaluation of abnormalities involving the distal CBD and ampulla,
Raman SP, Fishman EK including an emphasis on the use of multiplanar reformations and 3D imaging, the morpho-
logic 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 refor-
mations and 3D imaging to determine the correct diagnosis prospectively. A timely and cor-
rect 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; 203:17–28
0361–803X/14/2031–17
© American Roentgen Ray Society
T
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 differ-
ential diagnosis. The accurate radiologic
evaluation of this location is of great impor-
tance 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 stud-
ies of the distal CBD and ampulla, including
providing a differential diagnosis for ampul-
lary and distal CBD abnormalities and le-
sions, a perspective on when a dilated CBD
requires further evaluation with MRCP or
ERCP, and a discussion of the use of multi-
planar reformations (MPRs) and 3D imaging
to better assess the morphology of the dis-
tal 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 nor-
mal duct may be dilated in older patients and
those who have undergone cholecystectomy.
Thus, overemphasizing CBD measurements,
especially when the ducts are only mildly di-
lated, should be avoided, particularly in pa-
tients without symptoms (i.e., biliary colic,
right upper quadrant pain, jaundice) or bio-
chemical markers suggestive of biliary ob-
struction [2]. In patients with borderline en-
largement of the ducts without CT evidence
of a discrete obstructing mass or other sus-
picious imaging features, the best course of
action may be to simply recommend corre-
lation with clinical and biochemical mark-
ers 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-

AJR:203, July 2014 17


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 im-
ages are acquired; focal or diffuse bile duct
wall thickening; and a discrete mass.
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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 dis-
tal duct. Once a site of transition is found,
any evidence of irregularity, abrupt narrow-
ing, or “shouldering” at the transition point
should raise suspicion for malignancy. Al-
though this evaluation can be performed
using the source axial images, the use of
coronal and sagittal MPR images and 3D re-
constructions can be vital [3].
Technique
In any patient with a suspected pancreato-
biliary 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., ampul-
lary carcinoid, pancreatic neuroendocrine tu-
mors, hypervascular gastrointestinal stromal
tumors), subtle biliary tree mucosal hyperen-
hancement and thickening, and tumor neovas-
cularity and to evaluate the arterial anatomy
before surgery. The venous phase images are
used to evaluate the liver and pancreas for tra-
ditionally hypovascular tumors and metasta-
ses, locoregional lymphadenopathy, and in-
volvement 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 pancre-
as, ampulla, or duodenum: Not only will the
positive contrast agent obscure any intralu-
minal mass in the duodenum or near the am-
pulla, but also streak artifact from the con-
trast agent will make evaluation of subtle
duodenal wall thickening or hyperenhance-
ment near the ampulla difficult to perceive
and can interfere with 3D postprocessing al-
gorithms. Instead, a neutral contrast agent
such as water or a barium suspension (VoL-
umen, Bracco Diagnostics) should be used,
and some portion of this contrast medium
should be given to the patient immediately
18 AJR:203, July 2014
Raman and Fishman
before scanning to maximize gastric and du-
odenal distention [4].
After the acquisition of source axial imag-
es and reconstruction of standard MPRs, we
have found three image postprocessing re-
construction algorithms (including 3D post-
processing) to be the most useful for image
interpretation: volume rendering (VR), min-
imum intensity projections, and curved pla-
nar reformations. VR is a complex, compu-
tationally intensive computer algorithm that
assigns a specific color and transparency to
each voxel in a dataset on the basis of its at-
tenuation 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 re-
construction tools and is a vital component
of biliary analysis. This technique is useful
not only for increasing the conspicuity of ob-
structing lesions, but also for increasing the
conspicuity of subtle biliary hyperenhance-
ment and thickening [4, 5].
Minimum-intensity-projection reconstruc-
tions rely on the same principles as maxi-
mum-intensity-projection (MIP) imaging.
However, unlike MIP reconstructions, which
project the highest-attenuation voxels in a da-
taset, minimum-intensity-projection recon-
structions project the lowest-attenuation vox-
els, 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 obstruct-
ed. At our institution, although MIP images
are not a major component of biliary tree 3D
analysis, minimum-intensity-projection re-
constructions are performed in every case, and
we have experienced great success in identify-
ing 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 cor-
onal, 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 adenoma—Adenomas 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 loca-
tion is in proximity to the ampulla of Vater
[9]. These lesions are most common in elder-
ly patients, and other than familial adenoma-
tosis 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 co-
lon, these lesions usually contain foci of low-
grade dysplasia and have the potential to de-
velop higher-grade dysplasia and invasive
carcinoma, particularly as they grow larger.
Up to 60% of ampullary adenomas are ul-
timately found to harbor at least some foci
of invasive carcinoma (especially in large
lesions), so the preoperative distinction be-
tween an adenoma and an ampullary carci-
noma 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 am-
pullary carcinomas (Figs. 1 and 2).
Cholangiocarcinoma—Although cholangio­
carcinomas of the extrahepatic duct have
a strong predilection for the proximal one
third of the duct, up to 20% of lesions oc-
cur in the distal one third and 95% of pa-
tients show ductal obstruction at the time
of diagnosis [10]. Traditionally, both intra-
hepatic and extrahepatic cholangiocarcino-
mas have been classified into three different
morphologic subtypes, each of which pres-
ents with a different appearance on imaging:
mass-forming cholangiocarcinoma, periduc-
tal infiltrating cholangiocarcinoma, and in-
traductal cholangiocarcinoma.
The mass-forming cholangiocarcinoma
is the easiest of the three subtypes to diag-
nose: It usually presents as a discrete mass
or nodule that obstructs the extrahepatic bile
duct. This mass does not have to be partic-
ularly large to obstruct the duct, and both
the source axial images and coronal MPRs
should be scrutinized for evidence of a dis-
crete nodule. Like intrahepatic cholangio-
carcinoma, these lesions can show some hy-
pervascularity on arterial phase images and

increased enhancement on delayed images,
making multiphase protocols extremely use-
ful for diagnosis [10, 11].
The periductal infiltrating variant can be
more difficult to identify; it often presents as
asymmetric bile duct wall thickening and en-
hancement at the site of transition in the di-
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lated biliary tree and usually involves only a
short segment. These tumors can rarely in-
volve a larger segment of the bile duct, some-
times extending into the intrahepatic biliary
tree, and can rarely be mistaken for an in-
flammatory process. In our experience, vol-
ume-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. 3–5).
Finally, the intraductal variant is quite
rare and can have a variable morphology that
is not readily distinguishable from the oth-
er two morphologic subtypes on CT. These
lesions tend to spread along the inner sur-
face of the bile duct, either as a superficial-
ly spreading mass that presents as focal wall
thickening or as a discrete intraluminal poly-
ploid mass [10].
Ampullary carcinoma—Although radiol-
ogists often regard the ampulla as a single
anatomic entity, it is actually a region com-
posed of multiple different structures, the
most important of which are the distal CBD,
downstream pancreatic duct, and duodenum.
Accordingly, this region is composed of sev-
eral different types of epithelium, including
intestinal epithelium (duodenum), foveolar-
like mucosa (papilla of Vater), and pancre-
atobiliary epithelium (distal CBD and pan-
creatic 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, patholo-
gists 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 intraam-
pullary tumors showing histologic overlap
with combined duodenal and pancreaticobil-
iary 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 ori-
gin within the ampulla and relatively earlier
AJR:203, July 2014 19
CT of the Distal CBD and Ampulla
presentation because of a greater propensi-
ty for early, severe ductal obstruction and a
lesser invasive component. Alternatively, tu-
mors arising from the pancreatobiliary epi-
thelium tend to have a worse prognosis, with
both histology and prognosis relatively sim-
ilar to pancreatic adenocarcinoma. Finally,
tumors arising from the duodenal mucosa
tend to be large at presentation with a great-
er propensity for lymph node metastases but
with a prognosis roughly comparable to duo-
denal adenocarcinoma [12].
Regardless of this pathologic distinction,
these three subtypes cannot be reliably dis-
tinguished on any imaging modality includ-
ing CT. Kim et al. [13] reported that ampulla-
ry carcinomas obstructed both the pancreatic
and biliary ducts in 52% of cases and that
48% of cases showed only biliary ductal dil-
atation. These results likely reflect the differ-
ent 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 ex-
traordinarily rare. The lesion can appear as a
discrete nodular mass or as ill-defined soft-
tissue 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 im-
ages will often show an abrupt margin or ir-
regularity at the site of transition in the CBD,
which should definitely precipitate further
evaluation with ERCP [13–15] (Figs. 6–10).
Ampullary carcinoid—Although ampulla-
ry 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]. In-
terestingly, ampullary carcinoids are thought
to be biologically distinct from other small-
bowel or duodenal carcinoid tumors, with
ampullary carcinoids showing a higher pre-
dilection for metastatic disease [17]. These
tumors tend to present as small lesions, can
develop nodal disease even when the pri-
mary 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 ob-
struct the biliary tree, these tumors invariably
are treated with a pancreaticoduodenectomy
(Whipple procedure) [18].
Like carcinoid and neuroendocrine tu-
mors elsewhere in the bowel or the pancre-
as, ampullary carcinoid tumors (and their lo-
coregional 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 adja-
cent pancreatic head should allow the radiol-
ogist to prospectively suggest that the tumor
arises from the ampulla rather than the pan-
creatic head or the adjacent duodenal wall.
Pancreatic adenocarcinoma—In some
cases, differentiation of a primary pancre-
atic head or uncinate process adenocarcino-
ma 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 ex-
act site of origin of a lesion may not be im-
mediately evident, particularly with pancre-
atic adenocarcinomas primarily centered in
the pancreaticoduodenal groove (an anatom-
ic 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 pancreaticoduode-
nectomy. In our experience, primary ampul-
lary 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.
12–14). 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 pan-
creatic head rather than the ampulla.
Periampullary duodenal carcinoma—The
duodenum and proximal jejunum are the most
common sites for the development of small-
bowel 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 ob-
struction, the distinction between a prima-
ry periampullary duodenal adenocarcinoma
and a primary ampullary carcinoma is impos-
sible to make based on imaging alone (Fig.
15). Once again, although these lesions arise
in very close anatomic proximity, their bio-
logic behavior tends to be different: Adsay et
al. [12] reported that duodenal adenocarcino-
mas were usually less advanced at presenta-
tion (i.e., lesser T stage and less likely to har-
bor lymph node metastases) than ampullary
tumors and that patients with duodenal adeno-
carcinomas typically had better survival rates.
Benign Causes
Distal common bile duct stones—There
is little argument that CT is not the prima-

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]. How-
ever, the poor reputation of CT in evaluating
biliary stones has almost certainly been exag-
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gerated 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 easi-
ly identified, often with a “rim” or “crescent”
of surrounding bile, whereas soft-tissue–den-
sity stones can be more difficult to visualize
[20] (Fig. 16). Thus, visualization of choles-
terol stones, which are often isodense to sur-
rounding 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 impos-
sible 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 histo-
ry of cholecystectomy or gallstones. The use
of narrow window settings is vital for iden-
tifying subtle soft-tissue–density stones and
the use of multiplanar and curved planar ref-
ormations is helpful for tracing the extrahe-
patic 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 di-
lated CBD at the ampulla, often with a well-
marginated “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 [21–24] (Figs. 17 and 18).
Some practices use unenhanced images in
the belief that unenhanced imaging might in-
crease 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 clini-
cal practice, CT examinations performed
at higher tube voltage settings (usually 140
kVp) may increase the conspicuity of stones
and, in particular, may increase the attenu-
ation and conspicuity of cholesterol stones
that are difficult to perceive on standard im-
ages [25, 26]. This increased conspicuity of
20 AJR:203, July 2014
Raman and Fishman
stones at higher tube voltage settings may of-
fer a source of potential clinical utility for
dual-energy CT as this technology becomes
more widely used in practice.
Benign biliary strictures—The list of dif-
ferent causes of benign biliary strictures is
long and extensive, with the most common
causes including prior iatrogenic injuries
(most often after cholecystectomy and liv-
er transplantation), chronic pancreatitis, and
primary sclerosing cholangitis (PSC). Other
more rare causes include HIV cholangiopa-
thy, unusual infections (including tuberculo-
sis) (Fig. 19), Mirizzi syndrome, inflammato-
ry strictures from certain chemotherapy drugs
and other medications, radiation therapy, por-
tal biliopathy, and sarcoidosis [27–29]. Al-
though a detailed discussion of each of these
entities is beyond the scope of this article, cer-
tain entities are important to consider when
dealing with obstruction of the distal CBD,
including chronic pancreatitis, PSC, and stric-
tures 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 pancreati-
tis—including pancreatic ductal irregularity
and beading, parenchymal and ductal calci-
fication, pancreatic pseudocysts, and pancre-
atic atrophy—in the setting of pancreatic and
biliary ductal dilatation should strongly raise
the possibility of this diagnosis [27]. How-
ever, given that patients with chronic pancre-
atitis are at increased risk of developing pan-
creatic cancer and the fact that some patients
can develop a fibroinflammatory mass at the
pancreatic head, the distinction between be-
nign and malignant strictures at this site may
not be a simple one [31–33].
PSC very rarely involves the extrahepat-
ic bile duct without abnormalities of the in-
trahepatic ducts. As a result, when consid-
ering this diagnosis in a patient with a CBD
stricture, it is imperative to closely evaluate
the intrahepatic ducts for characteristic fea-
tures, including beading of the ducts and al-
ternating sites of ductal narrowing and dila-
tation. 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 10–30% 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 suspi-
cious 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 wide-
spread availability of highly active antiret-
roviral therapy (HAART), HIV cholangi-
opathy 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 cholan-
giocarcinoma, ampullary neoplasm, or in-
flammatory 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 associ-
ated with suspicious locoregional lymphade-
nopathy 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, ta-
pered narrowing rather than an abrupt mar-
gin or shouldering [2].
Conclusion
In our experience, both the distal CBD
and the ampulla are common sites of missed
diagnoses for radiologists. Avoiding mis-
takes in interpreting imaging findings in this
location requires a systematic approach es-
pecially in the setting of unexplained biliary
ductal dilatation. Rather than simply sug-
gesting that MRCP or ERCP be performed
for the ultimate diagnosis, radiologists can
perform a careful CT evaluation using mul-
tiplanar reformations and 3D imaging to de-
termine 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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(Figures start on next page)
 Raman and Fishman
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A B

Fig. 1—75-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.

A B

Fig. 2—70-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.

22 AJR:203, July 2014

 CT of the Distal CBD and Ampulla
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A B

Fig. 3—75-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. 4—75-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. 5—60-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.

AJR:203, July 2014 23

 Raman and Fishman
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Fig. 6—51-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. 7—53-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.

A B

Fig. 8—69-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.

24 AJR:203, July 2014

 CT of the Distal CBD and Ampulla
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Fig. 9—69-year-old woman who presented with jaundice and abdominal pain. Fig. 10—67-year-old man who presented with jaundice. Coronal volume-
Coronal volume-rendered CT image shows focal wall thickening (arrows) along rendered CT image shows focal mass (arrow) at ampulla obstructing distal
medial duodenal wall at level of ampulla, which was ultimately found to be common bile duct (CBD). Distal CBD is abruptly narrowed and irregular. This
ampullary carcinoma. mass was ultimately found to be ampullary carcinoma.

A B

Fig. 11—49-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.

AJR:203, July 2014 25

 Raman and Fishman
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A B C

Fig. 12—78-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. 13—46-year-old woman who presented with
painless jaundice. Coronal minimum-intensity-
projection 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.
Fig. 14—75-year-old man who presented with
jaundice and abdominal pain. Coronal volume-
rendered 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. 15—71-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.

26 AJR:203, July 2014

 CT of the Distal CBD and Ampulla
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Fig. 16—76-year-old man with known cholelithiasis
on prior ultrasound. Axial CT image shows soft-
tissue–density stone (arrow) in distal common
bile duct and ampulla with characteristic rim of
surrounding bile.
Fig. 17—84-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. 18—91-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. 19—78-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.

AJR:203, July 2014 27

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A B

Fig. 20—30-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.

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28 AJR:203, July 2014