Anatomy of the choledochopancreatic duct junction in primary sclerosing cholangitis

Primary sclerosing cholangitis (PSC) is a rare disease for which the etiology is unknown. Because abnormalities of the choledochopancreatic duct junction (CDPDJ) have been implicated in the pathogenesis of other rare iliary problems such as choledochal cysts and biliary atresia, we reviewed the cholangiographic anatomy of the CDPDJ in our patients with PSC. From 1955 through July 1983, 46 patients with PSC were seen at the University of California at Los Angeles Medical Center. In 20 of these 46 patients anatomy of the CDPDJ could be evaluated by review of endoscopic retrograde cholangiopancreatography (11 patients) or by reflux into the pancreatic duct during transhepatic, operative, or postoperative tube cholangiography (nine patients). Roentgenograms were evaluated for the length of common channel of the biliary and pancreatic ducts and the degree of reflux into and anatomic abnormalities of the pancreatic duct. All bile ducts were abnormal, and pancreatic duct reflux occurred in 14 of 42 patients (33%) who underwent transhepatic or tube cholangiography. An abnormally long (> 15 mm) common channel was present in two of 20 patients (10%), pancreatic duct reflux of more than 100 mm occurred in six of 14 patients (43%), and pancreatic duct abnormalities were seen in nine of 18 patients (50%). These data suggest that in patients with PSC abnormal pancreatic duct reflux and anatomy are common but variations in the anatomy of the CDPDJ are rare. However, altered function of the CDPDJ may contribute to excessive reflux into and anatomic changes of the pancreatic ducts and the moderate incidence of pancreatitis observed in patients with PSC.