HighlightsWhat is already known on this topic?Duplex gallbladder is a rare congenital abnormality.What this study adds?The importance of thorough investigation to avoid missed diagnosis.Surgery is only indicated for symptomatic duplex gallbladders.

East Lancashire Hospitals NHS Trust, UKABSTRACT INTRODUCTION The aim of this study was to evaluate the influence of flurodeoxyglucose positron emission tomography computed tomography (FDG PET-CT), as an adjunct to conventional CT staging, in the detection of extrahepatic disease in patients with potentially resectable colorectal liver metastasis. METHODS Overall, 133 consecutive patients with colorectal liver metastases staged with CT and PET-CT referred to the East Lancashire regional hepatobiliary multidisciplinary team over a two-year period were included in this study. Abnormal findings on PET-CT were correlated with follow-up imaging and/or histology. All imaging was reviewed by specialist hepatobiliary radiologists for the presence/absence of extrahepatic disease. The influence of the PET-CT findings was categorised for each patient in relation to operability and other significant findings. RESULTS PET-CT had a major impact on staging of extra hepatic disease in 20% of patients, in comparison with the initial CT. Six per cent of patients were upstaged from operable CT findings to inoperable findings on PET-CT because of the discovery of inoperable occult extrahepatic disease. Five per cent had operable local regional nodal disease detected on PET-CT. A further 3% had premalignant colorectal lesions detected on PET-CT. Six per cent of patients were downstaged from indeterminate or suspected inoperable CT findings to operable findings on PET-CT. CONCLUSIONS The use of PET-CT in this setting may prevent futile operations, guide the resection of local regional nodal disease and downstage a number of patients thought to have extrahepatic disease on conventional imaging. This study has shown similar results to other recent studies and supports the use of PET-CT as a necessary staging modality in patients with potentially resectable colorectal liver metastases.

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ABSTRACT. Biliary cystadenomas are predominately benign tumours that have a low malignant potential. We present a case of a 30-year-old female with a histopathological confirmation of a biliary cystadenoma following resection. The diagnosis was made preoperatively by MRI using the hepatocyte-specific contrast agent gadobenate dimeglumine [Gd-BOPTA (MultiHance; Bracco Diagnostics Inc., Princeton, NJ)]. At the biliary excretory phase, delayed phase images demonstrated communication between the multilocular cystic mass and the biliary tree, which helped to confirm the diagnosis of biliary cystadenoma. This highlights the beneficial use of hepatocyte-specific agents for their dual function as an extracellular agent and a hepatobiliary agent.

IntroductionBouveret's syndrome refers to a gastric outlet obstruction due to the impaction of a large gallstone following retrograde migration via a bilio-duodenal fistula. Although no clear management guideline has been formulated, different treatment modalities have been described, including endoscopic stone removal using classical endoscopic devices, like snares and forceps, or fragmentation of stones with new devices, such as lasers and extracorporeal shockwave lithotripsy (ESWL). ResultsThis case series reports six patients who have been diagnosed with Bouveret's syndrome and have presented with interesting radiological and endoscopic findings. The report is followed by a literature review, including diagnostic and management options for this rare condition. DiscussionCholelithiasis is a common condition occurring in the general population and may develop rare complications such as cholecystoduodenal fistula. Bouveret's syndrome presents with a clinical picture similar to that of gastric outlet obstruction, and laboratory findings are often consistent with an obstructive jaundice picture. The use of endoscopic treatment with a range of different lithotripsy modalities has been described to manage this condition. ConclusionThe diagnosis of Bouveret's syndrome is made after performing appropriate imaging studies. The first-line management option is endoscopic treatment. If this fails, surgical intervention is recommended.

Background: Elevated serum bilirubin has been shown to be a reliable predictor of pancreatic and biliary malignancy but the relationship between serum bilirubin and inadequate (C1), benign (C2) and indeterminate (C3) cellular samples has not been explored. The aim of this study is to determine the relationship between serum bilirubin and pancreatic, biliary or ampullary malignancy in the context of non-confirmatory cytology. Methods: This is a retrospective analysis of patients with obstructive jaundice undergoing investigation for possible pancreatic, peri-ampullary or biliary malignancy between 2009 and 2013. Results: 135 patients were included; 84 had a malignant diagnosis and 51 benign. All patients with C4 or C5 cytology (n=49) had confirmed malignancy. 35 out of 86 C1-C3 samples were falsely negative. ROC curve analysis demonstrated a strong association (AUC 0.912) between elevated serum bilirubin and malignancy; serum bilirubin ≥ 100 µmol/L had a sensitivity of 86% and a specificity of 88%. In the C1-C3 subgroup, this association was maintained (AUC 0.905). Serum bilirubin ≥ 100 µmol/L had a sensitivity of 80% and specificity of 88%. Using this cutoff highlighted 28 out of 35 of the malignancies missed by cytology (p = 0.003). Conclusion: Our study demonstrates that a serum bilirubin ≥ 100 µmol/L is associated with malignancy and this relationship is maintained in C1-C3 cytology. When faced with non-confirmatory cytology in the absence of a benign aetiology and an elevated serum bilirubin ≥ 100 µmol/L, we advocate more aggressive investigation to avoid missing an occult malignancy.

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Colorectal cancer (CRC) is the second most common cause of cancer death in the US. Earlier detection can allow treatment with curative intent and improve prognosis. Optical and virtual colonoscopy are widely used in screening for colonic polyps and in the investigation of suspected CRC. However, contrast-enhanced computed tomography (CT) is still performed to investigate various non-specific abdominal complaints. Hence, a significant number of CRC are identified on contrast-enhanced CT without bowel preparation. We describe several signs, which when present in tandem, raise suspicion of CRC, and may warrant further investigation with optical colonoscopy. These include an intraluminal mass, eccentric or circumferential wall thickening >3 mm, focal wall enhancement, pericolic fat stranding, a cluster of >3 local lymph nodes, and enlarged lymph nodes >10 mm in short axis. Multiplanar evaluation of the bowel should be performed on all CT abdominal studies, including those without bowel preparation, to identify subtle features of CRC.