Tumors localized in the uncinate process may be associated with epigastric or back pain without jaundice. Ampullary carcinoma fell in between, and the benign lesions had no intra-hepatic or extrahepatic bile duct and pancreat-ic duct dilation. Iravani A, Richard GA, Johnson D, Bryant A "A double-blind, multicenter, comparative study of the safety and efficacy of cefixime versus amoxicillin in the treatment of acute urinary tract infections in adult." sphincter of Oddi dysfunctionSolid Pancreatic Masses Journal. Dr. Taco Geertsma is the founder of UltrasoundCases.info and a retired radiologist and has worked in the Gelderse Vallei hospital from January 1, 1983. till July 1, 2014. The double duct sign is an anatomical sign of combined dilatation of common bile duct and pancreatic duct that is highly diagnostic of pancreatic carcinoma in jaundiced patient. In selected patients without jaundice but with a double duct sign, pancreas cancer was only seen in 6% of patients. These patients had adenocarcinoma in 87% (n = 33/38), while the patients with double duct sign but without jaundice had adenocarcinoma in 43% (n = 16/37, p = 0.0003) as the final diagnosis. We present a case of a 67-year-old … Moreover, CT revealed no evidence of the double duct sign in our patient, except for double duct sign was most evident in pancre-atic head cancer. 2009;38(6):625-30. 445 Disorders of the biliary tract with cc. Surgical jaundice can be caused by the obstruction of the bile duct as with common bile duct (CBD) stones, strictures, malignancy, such as cholangiocarcinoma, periampullary carcinoma, carcinoma gallbladder, and carcinoma head of the pancreas. Jaundice. Diseases that cause both bile and pancreatic duct dilatation either involve the common channel (e.g., ampullary carcinoma) or are large enough to involve both ducts (e.g., pancreatic carcinoma). The prevalence of malignancy in these patients is not established. The double-duct sign, a simultaneous stenosis of the common bile duct and the pancreatic duct, is suggestive of the presence of a pancreatic cancer. ERCP demon-strated double duct sign. Dysfunction of sphincter of oddi. MRCP) can show “double duct sign” clearly. Double impaction: Stones, simultaneously occluding the cystic duct and the distal common bile duct (CBD). ... value of EUS-FNA in patients suspected of having pancreatic cancer with a focal lesion on CT scan/MRI but without obstructive jaundice. lumen, without the US signs of the inflammation of a gallbladder wall. Abstract. Previou- ampullary carcinoma in their small cohort of a very high prevalence of malignancy in sly unidentified CBD stones were noted in 6 14 patients with unexplained CBD dilation ≥15 patients with double duct sign and it is there- patients (3 in patients with ObJ and 3 in mm and without ObJ.11 Malik et al. Magnetic resonance (MR) cholangiography has proved effective in demonstrating bile duct dilatation, strictures, and choledocholithiasis (,1–,14). A CT with contrast and a MRI of the abdomen and pelvis revealed dilatation of the common bile duct and the pancreatic duct (double duct sign) with a hypodensity lesion of 1×1.3×3 cm at ampulla of Vater that infiltrated the surrounding fat (figures 1 and 2). In an unselected population, regardless of presenting symptoms, a double-duct sign on endoscopic retrograde cholangiopancreatography (ERCP) was caused by a pancreas malignancy in 58% of patients. Painless jaundice • Ultrasound- dilated bile duct • ERCP performed –stricture found; sampled for cytology –plastic stent placed Courvoisier's law states that, in a patient with obstructive jaundice, if the gallbladder is distended and palpable, it is not due to common bile duct stones. In selected patients without jaundice but with a double duct sign, pancreas cancer was only seen in 6% of patients. Double duct sign is an anatomical sign of combined dilatation of common bile duct and pancreatic duct. Low serum albumin suggests chronic liver disease. In an unselected population, regardless of presenting symptoms, a double-duct sign on endoscopic retrograde cholangiopancreatography (ERCP) was caused by a pancreas malignancy in 58% of patients. Abdominal ultrasound is not as sensitive as computed tom-ography in imaging the pancreas, and small tumours (less BMJ 337 (2008): a2117 The combined dilatation of pancreatic and common bile ducts is known as double duct sign and occurs most commonly in malignancy of the head of pancreas. Jaundice, also known as icterus, is a yellowish or greenish pigmentation of the skin and whites of the eyes due to high bilirubin levels. In 38% of cases there is a “double-barreled” opening at the apex of the papilla. This makes bile back up into the bloodstream and can cause jaundice. However, the blockage may not be caused by cancer. A gallstone or scar tissue can also block the bile duct. Jaundice is a common symptom of bile duct cancer. 1. Jaundice was suspected and magnetic resonance cholan-giopancreatography(MRCP)wasperformed.MRCPshowed that the common bile duct and the main pancreatic duct at the pancreatic head were both dilated (11 mm and 6 mm, respectively), without obstruction (Fig. A fusiform aneurysm of a distal-suprabifurcational- segment of the abdominal aorta was also visualized. dysfunction [3]. BILIARY ATRESIA. Without dispute, sphincterotomy should be omitted in this situation, as cutting inside a neoplasia carries an unjustifiable risk of bleeding and a potential risk of tumor spread. If the tissue shows fat without inflammation and damage, simple fatty liver or NAFLD is diagnosed. Figures from larger series are needed to support this conclusion. ere Postoperative outcome was favorable without any complications. Itching. 2. dilated billiary tree and dilated pancreatic duct tight stricture in the distal end of the cbd and tight narrowing of the distal end of the pancreatci duct full length dilatation of the pancreatic duct with no dilaltation of the ramifications 7. double duct sign strongly suggestive of malignant etiology 8. Download. Courvoisier's law states that a painless palpably enlarged gallbladder (known as Courvoisier's sign or Courvoisier-Terrier's sign, or Courvoisier syndrome) accompanied with mild jaundice is unlikely to be caused by gallstones.Usually, the term is used to describe the physical examination finding of the right-upper quadrant of the abdomen.This sign implicates possible malignancy … However, benign causes have also been reported to cause a double-duct sign. The combined dilatation of pancreatic and common bile ducts is known as double duct sign and occurs most commonly in malignancy of the head of pancreas. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). But whenever jaundice occurs, a doctor should be seen right away. ERCP showed gradually tapering appearance of the CBD (arrow) and PD (arrowhead) with double duct sign. Endoscopic retrograde cholangiopancreatography (ERCP) is the most valuable tool for further diagnosis as well as temporary or definitive therapy in patients with biliary strictures. Abdominal ul-trasound and abdominal CT scan demonstrated dilated bile ducts and a mass in the head of the pancreas. MRCP shows abrupt cut-off of common bile duct and main pancreatic duct in the pancreatic head (arrows), very suggestive of neoplasm. However, migration of the inserted stent can occur, either distally or proximally; proximal migration is less common, but it also presents a greater challenge for endoscopic resolution. It is observed on imaging during endoscopic retrograde cholangio-pancreatography, magnetic resonance cholangio-pancreatography, computed tomography and ultrasound. Or, the cause of a symptom or sign may be a medical condition that is not cancer. Double impaction: Stones, simultaneously occluding the cystic duct and the distal common bile duct (CBD). Endoscopic biliary decompression via stent placement is an important approach for the palliative management of distal malignant biliary obstruction. In selected patients without jaundice but with a double duct sign, pancreas cancer was only seen in 6% of patients. … This double duct sign is the simeltaneous presentation of a dilated pancreatic duct (MPD) and the CBD. Neonatal jaundice in most newborns is a mild and transient event. It is almost pathognomonic of carcinoma of the pancreas with the rare instances of chronic pancreatitis causing the obstruction. Bifid duct anatomy was confirmed via intraoperative probing and direct visualization of the ductal orifices. Jaundice is the most common symptom of bile duct cancer, but most of the time, jaundice isn't caused by cancer. 78441c01.8s painless jaundice pancreas mass bile ducts intrahepatic dilated extrahepatic gallbladder enlarged distended dilated gallstones cholelithiasis pancreatic duct double duct sign Courvoisier’s CTscan Courtesy Ashley Davidoff MD copyright 2008 “Double-duct sign” (strictures in both common bile duct [CBD] and pancreatic duct [PD] with proximal dilation) on endoscopic retrograde cholangiopancreatography is considered suggestive of pancreatic malignancy. with jaundice and a palpable gallbladder. AST and ALT are not usually raised in obstructive jaundice unless complicated by cholangitis. Mixed picture. The sign in a jaundiced patient is highly diagnostic of pancreatic carcinoma. IgG4-related disease had been well documented to involve many organs, such as lymph nodes, pancreas, salivary gland, thyroid gland, biliary tract, retroperitoneum, kidney, gallbladder, mesentery, lung and prostate. In this case the stricture appears quite distal. is a lack of opening in the biliary tree which will cause jaundice after birth. A dilatation of intra and ekstrahepatic biliary ducts as well as a dilatation of a common pancreatic duct was noted, producing the so called” double duct sign”. Double duct sign is an anatomical sign of combined dilatation of common bile duct and pancreatic duct. The combined dilatation of pancreatic and common bile ducts is known as double duct sign and occurs most commonly in malignancy of the head of pancreas. without evidence of bile duct disease ... painless jaundice, anorexia, wt loss, cholestastic sx’s (pruritis, dark urine, acholic stools), impaired glucose tolerance ... (“Double Duct Sign”) zManagement: • Biliary decompression if: cholangitis, pruritis, palliation The prevalence of jaundice in adults is rare, while jaundice in babies is common, … 2). Jaundice is a common symptom of bile duct cancer. Findings suggestive of a tumor/mass include super-impassable strictures, obstruction of the common bile and pancreatic ducts (the "double duct" sign), a pancreatic duct stricture in excess of 1 cm in length, pancreatic duct obstruction, and the absence of changes suggestive of chronic pancreatitis. The double duct sign (dilation of the extrahepatic common bile duct and the pancreas duct) is most often a sign of malignancy . Papillary mass of biliary tract. Acquired dilation of bile duct. ERCP revealed a double duct sign. The double duct sign is defined as coexistent and adjacent stenosis of the main pancreatic and CBD as seen on ERCP. Histology confirmed PDAC in this patient. Gastrointestinal Endoscopy publishes original, peer-reviewed articles on endoscopic procedures used in the study, diagnosis, and treatment of digestive diseases. Neonatal jaundice is yellowish discoloration of the skin, conjunctiva, and the sclera from elevated serum or plasma bilirubin in the newborn period. Pancreatic cancer had a larg-er diameter, a higher internal rate of necrosis, and the surrounding tissues had a higher vul-nerability to invasion. Clinical Significance of Dilated Common Bile Duct and Pancreatic Duct in Patients with Or Without Obstructive Jaundice. The stone in the CBD cuases obstructive jaundice and a synchronous stone in the cystic duct leads to mucocele or empyema of gall bladder. obstructive jaundice include jaundice with or without pain,dark urine, pruritis, pale stools, weight loss, anorexia. Thirty-eight patients had both jaundice and double duct sign at presentation. The two most common causes of the double duct sign are carcinoma of the head of the pancreas and ampullary tumors , although occasionally an impacted gallstone in the distal duct, with associated edema, can also result in obstruction of the pancreatic duct. toms of obstructive jaundice, pancreatitis, weight loss, and abdominal pain.7 However, early diagnosis of ampul-lary cancer in our patient was difficult because of the small tumor size, anicteric course, and normal biliary and pancreatic enzyme levels. Double-duct sign (combined dilatation of the common bile duct and pancreatic duct) is an infrequently encountered finding in cross-sectional radiological imaging of the pancreatobiliary system. IgG4-related disease had been well documented to involve many organs, such as lymph nodes, pancreas, salivary gland, thyroid gland, biliary tract, retroperitoneum, kidney, gallbladder, mesentery, lung and prostate. Therefore, esophagogastroduodenoscopy (EGD) and endoscopic retro- Received November 21, 2004; revision requested January 1, 2005; revision received January 14; final version accepted February 16. The patient underwent pancreaticoduodenectomy with lymph node resection. 14 ERC also provides the opportunity for biopsy or brushing of the bile duct to obtain a tissue diagnosis. 1 From the Department of Computed Tomography, Centro Radiológico Luis Méndez Collado, Muñecas 444, San Miguel de Tucumán, Tucumán 4000, Argentina. Image 2 (ERCP): "Double-duct" sign - strictures are seen in the common bile duct (yellow arrow) and pancreatic duct (grey arrow) with dilatation of the pancreatic duct. ARDMS Gallbladder and Billiary System. Jaundice is the most common presenting sign and symptom of malignant biliary obstruction. A fusiform aneurysm of a distal-suprabifurcational- segment of the abdominal aorta was also visualized. This sign is commonly deemed to signify on ominous pathology and suggests the presence of … For example, it is experienced by up to 80% of patients with PBC and PSC and by 5–15% of patients with chronic hepatitis C at any time during the course of their disease. In patients with Chronic pancreatitis can also rarely cause the “double duct” sign. Rarely, a small amount of gas may be seen in the distal GI tract in the presence of biliary/pancreatic duct variations proximal duodenum with no contrast seen distally, however, the study is not usually performed because radiographs are essentially diagnostic. When a mass is not detected on EUS, subsequent evidence of malignancy is unlikely. Our results show that “double duct” sign in the absence of jaundice makes a malignant aetiology unlikely. Conclusion In patients with cross-sectional imaging evidence of “double-duct” sign, the absence of jaundice makes a malignant aetiology unlikely. Conversely, in jaundiced patients a malignant cause is much more likely. ADENOMYOMATOSIS. Conversely, in jaundiced patients a malignant cause is much more likely. Oriental cholangiohepatitis. Findings suggestive of a tumor/mass include super-impassable strictures, obstruction of the common bile and pancreatic ducts (the "double duct" sign), a pancreatic duct stricture in excess of 1 cm in length, pancreatic duct obstruction, and … Both CT and MR (esp. e double-duct sign usually indi2, - cates pancreatic malignancy with a lower prevalence in patients who do not have obstructive jaundice [8]. The double-duct sign, a simultaneous stenosis of the common bile duct and the pancreatic duct, is suggestive of the ... was smooth without irregularities, suggesting a compression ... patients without severe jaundice (bilirubin o10 mg dl 1) and coagulopathy. Dilation of CBD and PD is frequently noted on computed tomography/magnetic resonance imaging scans, sometimes found incidentally in patients without jaundice. Please call our helpline at 1-800-GO-LIVER if you have questions after speaking with your healthcare professional. Author Dr. Taco Geertsma Retired Radiologist, Gelderse Vallei Hospital. None of the anicteric patients were found to have malignancy (P = 0.002). The double-duct sign is defined as dilation of both the common bile duct and pancreatic duct, which usually indicates pancreatic malignancy. Jaundice is the abnormal yellowing of the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. Patients with double-duct signs. Articles report on outcomes research, prospective studies, and controlled trials of new endoscopic instruments and treatment methods. Background: The double duct sign, a simultaneous stenosis of the common bile duct and the pancreatic duct by endoscopic retrograde cholangiopancreatography (ERCP), has been reported to predict the presence of pancreatic cancer with a high degree of certainty. “double-duct sign” (dilatation of the biliary and pancreatic ducts) occurs in less than 5% of patients with pancreatic carcinoma. BILOMA. among the possible causes of obstructive jaundice. PLAY. Common presentations leading to the diagnosis of the double duct sign include jaundice, itching, weight loss and non specific When the tumor locates in the neck, body or tail, it causes only upstream pancreatic duct dilatation ( Figure 10 ). In 2% there are separate duodenal openings for the two canals. iductal obstruction is a nonspecific sign and may also be seen in bile duct or ampullary carcinoma, metastases, chronic pancreatitis, and ampullary stenosis.28 For MRI, dynamic T1-weighted fat-suppressed What has the following lab findings: The term jaundice is from the French word "jaune," which means yellow. The double duct sign refers to the presence of simultaneous dilatation of the common bile and pancreatic ducts. Note double-duct sign (black arrows) point to abrupt cut off and dilatation of the common bile duct and pancreatic duct. Pancreatic duct dilatation, Double duct sign-the presence of a biliary and pancreatic duct dilatation, which may lead to focal atrophy of the gland, If a mass is sufficiently large it will, Distort the contour of the gland, Loss of pancreatic lobulation is also often an early sign 3. ... reveals obstruction of the common bile duct (arrowhead) and pancreatic duct (arrows) at the same point by this mass (“double duct” sign). Carcinoma of ampulla of Vater A 64 years old male presented with painless jaundice. But whenever jaundice occurs, a doctor should be seen right away. Methods: To test the specificity of the double duct sign for pancreatic cancer in patients with malignant and benign pancreatic … b Lack of double duct sign in CP (57 y, female). Sometimes, people with bile duct cancer do not have any of the signs and symptoms described below. 52. The role of imaging is crucial for detection of site, extent and cause of obstruction. A 57 year old female presents with jaundice. of bile duct obstruction, identify ampullary and periampullary lesions – however, malignant lesions may not be excluded by ERCP, necessitating resection anyway – double duct sign (superimposable bile duct and pancreatic duct strictures with proximal duct dilation) is suggestive of pancreatic head cancer The combination of painless jaundice and an enlarged gallbladder is termed Courvoisier’s sign. Conclusions In patients with MRCP evidence of double-duct sign, the absence of jaundice makes a malignant etiology unlikely. Raised serum alkaline posphatase level is often seen. We performed a PubMed search in July 2020 with ’double-duct sign’ as search term. In aca-demic literature, other rare cases of the double-duct sign have been reported. Double Duct Sign in a 3-Year-Old Child Malay Sharma, Barathkumar Mookiah, and Ruth Shifa Hari Jaswant Rai Speciality Hospital, Meerut, Uttar Pradesh, India Question: A 3-year-old boy from a family of low socioeconomic status living in a tropical country presented with complaint of upper abdominal pain, high-grade fever, and jaundice. Contrast enhanced CT showed: (a) intra hepatic dilated bile ducts. The double duct sign initially described on endoscopic retrograde cholangiopancreatography (ERCP) has also been seen with US, CT or MRCP and is usually caused by cancer of the pancreatic head or ampulla of Vater and less commonly, chronic pancreatitis or ampullary stenosis. When the bile duct is blocked, the liver cannot excrete bile. Case Report: A 64-year-old man with cystic liver and kidney disease and renal insufficiency on hemodialysis presented with abdominal pain and jaundice. Her ERCP shows dilatation of the bile duct and pancreatic duct – the “double duct” sign characteristic of adenocarcinoma of the head of the pancreas. Exceptions of Courvoisier’s law. Endoscopic Ultrasound (EUS): The combined dilatation of pancreatic and common bile ducts is known as double duct sign and occurs most commonly in malignancy of the head of pancreas. Adenocarcinoma. A dilatation of intra and ekstrahepatic biliary ducts as well as a dilatation of a common pancreatic duct was noted, producing the so called” double duct sign”. In this retrospective analysis, consecutive patients who underwent endoscopic ultrasound (EUS) at a tertiary care hospital from 2002 to 2006 for suspected pancreatic malignancy … 51. On 2D and 3D MRCP the pancreatic and biliary ducts can be accurately studied and the typical “double duct” sign, often seen with pancreatic or ampullary tumors, can be demonstrated ( Figure 46-10 ). Jaundice in adults is typically a sign indicating the presence of underlying diseases involving abnormal heme metabolism, liver dysfunction, or biliary-tract obstruction. Here the configuration by imaging with both endoscopic retrograde cholangiopancreatography and endosonography, in a case with pancreatic head carcinoma is demonstrated. Jaundice is the most common symptom of bile duct cancer, but most of the time, jaundice isn't caused by cancer. Bell CL, Watson B, Waring WS "Acute psychosis caused by co-amoxiclav." ICD-10-CM K83.8 is grouped within Diagnostic Related Group (s) (MS-DRG v39.0): 444 Disorders of the biliary tract with mcc. We present the case of a 59-year-old Caucasian female patient admitted to the Gastroenterology Department with intermittent right epigastric … a Double duct sign in PDAC (62 y, male). A computed tomography scan and a magnetic resonance imaging showed double-duct dilation (common bile duct diameter at 14.5 mm and main pancreatic duct at 6.5 mm) and obstruction at the papilla without duodenal mass . 97. Pancreas. Patients with jaundice in the context of double-duct sign had a higher incidence of malignancy (48%). ... What is a distended GB without wall thickening and obstructive neoplasm of distal bile duct? Serum bilirubin was 7.6 mg/dL and alkaline phosphatase 550 IU. STUDY. ERCP showed gradually tapering appearance of the CBD (arrow) and PD (arrowhead) with double duct sign. Symptoms of a blocked bile duct include: Yellowing of the skin (jaundice) or eyes (icterus), from the buildup of a waste product called bilirubin. ... --Painless jaundice--Epigastric pain radiating to back. Previou- ampullary carcinoma in their small cohort of a very high prevalence of malignancy in sly unidentified CBD stones were noted in 6 14 patients with unexplained CBD dilation ≥15 patients with double duct sign and it is there- patients (3 in patients with ObJ and 3 in mm and without ObJ.11 Malik et al. duct with an irregular wall (vs a single localised stricture); (4) no to mild upstream duct dilatation despite a long stricture (vs marked upstream duct dilatation); (5) double duct sign without a pancreatic mass in a patient with obstructive jaundice (vs a visible mass); (6) … The two most common causes of the double duct sign are carcinoma of the head of the pancreas and ampullary tumors , although occasionally an impacted gallstone in the distal duct, with associated edema, can also result in obstruction of the pancreatic duct. It's more often caused by hepatitis (inflammation of the liver) or a gallstone that has traveled to the bile duct. A 38-year-old male from Iraq without any history of previous infections presented at our institute with recently developed jaundice caused by a pancreatic head mass. It's more often caused by hepatitis (inflammation of the liver) or a gallstone that has traveled to the bile duct. In selected patients without jaundice but with a double duct sign, pancreas cancer was only seen in 6% of patients. The presence of double-duct sign on EUS in patients without jaundice or mass lesion on CT/MRI is most frequently associated with benign conditions. A CT scan of the abdomen showed the mass in the pancreatic head without lymph node involvement or infiltration of the vascular structures (Image 1). Conclusion In patients with cross-sectional imaging evidence of “double-duct” sign, the absence of jaundice makes a malignant aetiology unlikely. Double Duct Sign in a 3-Year-Old Child Malay Sharma, Barathkumar Mookiah, and Ruth Shifa Hari Jaswant Rai Speciality Hospital, Meerut, Uttar Pradesh, India Question: A 3-year-old boy from a family of low socioeconomic status living in a tropical country presented with complaint of upper abdominal pain, high-grade fever, and jaundice. Am J Med 85 (1988): 17-23. No lymph node invasion or metastasis was suspected. A decision was made for the performance of an end-to-site double duct to mucosa pancreaticojejunostomy. dilated bile duct, anterior to the portal vein also known as double-barrel shotgun. It's possible to live without a pancreas. Double Duct Sign. from the bile duct nor from the pancreatic duct, even after several minutes. The presence of double-duct sign on EUS in patients without jaundice or mass lesion on CT/MRI is most frequently associated with benign conditions. Bile duct dilation (>7 mm, or >10 mm if previous cholecystectomy) with pancreatic duct dilation (>2 mm) can be an indirect sign of pancreatic cancer (the so called double duct sign). This article is part of an expert video encyclopedia. lumen, without the US signs of the inflammation of a gallbladder wall. The stone in the CBD cuases obstructive jaundice and a synchronous stone in the cystic … The sensitivity and specificity of the double-duct sign observed by ERCP for pancreatic cancer varies between 50-76% and 63-80%, respectively. Coronal CT image through the upper abdomen in a 45-year-old male patient with painless jaundice showing a “mushroom”-shaped lesion consistent with an ampullary tumour (white arrows). double duct sign - bile duct dilation (>7 mm, or >10 mm if previous cholecystectomy) with pancreatic duct dilation (>2 mm) may be a sign of pancreatic cancer ; other findings - liver metastases and ascites ... People without jaundice who have pancreatic abnormalities on … Itching. (b) the ‘double duct’ sign with dilatation of both the CBD and pancreatic duct, and distension of the … The presence of strictures in both the CBD and pancreatic duct with proximal dilation (double duct sign) is also highly suggestive of a malignant etiology in jaundiced patients . Occasionally LFTs may indicate both cholestasis and hepatocyte damage, and this is usually due to cholangitis associated with stones in the common bile duct. It is, however imperative to identify newborns with jaundice that do not follow … The double duct sign is defined as coexistent and adjacent stenosis of the main pancreatic and CBD as seen on ERCP. The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of … If a hard gallbladder is palpated in a patient with jaundice without causing pain, the Courvoisier’s sign is positive, indicating a pancreatic head carcinoma until proved otherwise. A double-duct sign is the combined dilatation of the common bile duct and pancreatic duct, often caused by cancer of the pancreas. We present a patient with colicky pain in the right upper quadrant of her abdomen. On radiological imaging and endosonography, she had a double-duct sign due to choledocholithiasis and no mass in the pancreatic head. The double duct sign refers to the presence of simultaneous dilatation of the common bile and pancreatic ducts. Dilation of the main pancreatic duct and biliary duct could be caused by a luminal stricture in the distal bile duct in many, if not in all of the cases. Courvoisier's law states that, in a patient with obstructive jaundice, if the gallbladder is distended and palpable, it is not due to common bile duct stones. Plain radiographs reveal the double bub-ble sign without distal bowel gas (FIGURE 1). You can read more detailed information about preparing for a liver biopsy here . However, a high-grade and long stricture of both the distal common bile duct … Objectives: "Double-duct sign" (strictures in both common bile duct [CBD] and pancreatic duct [PD] with proximal dilation) on endoscopic retrograde cholangiopancreatography is considered suggestive of pancreatic malignancy. Courvoisier's law states that, in a patient with obstructive jaundice, if the gallbladder is J Gastrointest Canc (2014) 45 (Suppl 1):S178–S181 DOI 10.1007/s12029-014-9620-0 CASE REPORT Xanthogranulomatous Inflammation of Gallbladder and Bile Duct Causing Obstructive Jaundice Masquerades Gallbladder Cancer: a Formidable Diagnostic Challenge Continues Pankaj Kumar Garg & Durgatosh Pandey & Asit Ranjan Mridha & Rakesh Shakya & … Albumin. The double duct sign is now more commonly visualised by imaging modalities such as magnetic resonance cholangiopancreato-graphy (MRCP), computed tomography (CT) scan and even ultrasound studies. A stent was placed across the bile duct stricture. At this point, it is decided to restore bile flow by plastic stent placement before surgery. Rarely, the tumor in the pancreatic head stricts only CBD, and only the bile ducts are dilatated. 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