Tumor of the pancreatic head causing an unusually long biliary stricture

A 55 year old patient with metastatic tumor of the head of pancreas. The ampulla seemed normal. Contrast injection outlined dilated intrahepatic bile ducts (A: white arrows) and a dilated upper CBD. The mid and lower CBD was strictured and narrow (A: green arrows). We did a small papillotomy to allow the stent assembly to pass with ease and deployed a self expanding metallic stent of 8mm diameter and 80mm length (B: white arrows. C: white arrows show the deployed stent and washout of contrast from the biliary tree) . The longer stent was required due to a longer stricture, unexpected in tumors of the head of pancreas where usually 6 cm long stents suffice.

Tumor of the pancreatic head causing obstructive jaundice

A mass of approximately 21cm size in the region of pancreatic head was cashing obstructive symptoms in this 78 year old gentleman. He had also developed fever. His CT scan showed a dilated pancreatic duct (A1: green arrow)  with abrupt obliteration of its lumen (A2: green arrow) with an adjacent mass in the pancreatic head (A2: red arrow). On ERCP, his cholangiogram showed significant intrahepatic biliary dilatation (B: white arrows) with a stricture involving the distal CHD and proximal CBD (B: green arrows). He was in good physical shape and the remaining CT films didn't show any contraindications to resection. We placed a 10cm long plastic stent of 10 French diameter to drain the biliary system and resolve the infection (C: white arrows). He is due to undergo surgery soon after.

Carcinoma of pancreatic head causing obstructive jaundice

A 52 year old gentleman with jaundice secondary to a tumor of the pancreas (remember Courvoisier's law). The CT findings were of a dilated gallbladder (A: green arrow) and dilated CBD and pancreatic ducts (A: yellow arrow-the "double duct sign") with a pancreatic mass (A: red arrow). On ERCP,  contrast injection outlined a markedly dilated CBD and intrahepatic channels (B1 & B2: green arrows) with a sharp cutoff point near the level of cystic duct. A plastic 10F x10 cm stent was placed (C: red arrows)