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Age: 53

Sex: Female

Indication: Jaundice

Sonographic Murphy sign: Negative

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Case #37


Findings

  • Dilated main pancreatic duct, measuring up to 8 mm in diameter, with an ill-defined hypoechoic mass in the pancreatic head measuring 2.9 x 2.7 x 2.4 cm
  • Extrahepatic biliary duct dilation with the common bile duct measuring up to 11 mm in diameter and echogenic material noted in the distal common bile duct
  • Borderline gallbladder wall thickening and mild gallbladder distension with layering gallstones and sludge
  • Normal appearance of the liver and right kidney
  • No ascites
  • Visualized portions of the abdominal aorta are normal in caliber


Diagnosis

Pancreatic adenocarcinoma

Sample Report

Dilated main pancreatic and common bile ducts (“double duct sign”) with an ill-defined hypoechoic mass in the pancreatic head measuring 2.9 x 2.7 x 2.4 cm, concerning for pancreatic malignancy. Recommend surgical consultation and contrast-enhanced CT for further assessment.

Echogenic material layering in the distal common bile duct, which may represent sludge; however, recommend correlation with clinical signs of ascending cholangitis.

Borderline gallbladder wall thickening and mild gallbladder distension with layering gallstones and sludge, which are favored secondary to distal biliary obstruction rather than acute cholecystitis.


Discussion

  • The “double duct sign” of both pancreatic and biliary duct dilation equals cancer until proven otherwise
  • Even if no obstructing mass is identified on ultrasound, further imaging assessment with CT, MRCP, or even ERCP is needed
  • When visible on ultrasound, pancreatic adenocarcinoma usually presents as an ill-defined hypoechoic mass
  • Biliary duct obstruction can also lead to gallbladder distension and layering sludge, which is the imaging correlate to the Courvoisier sign – patient presentation with an enlarged, nontender gallbladder and jaundice



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