E1249. Painless Jaundice and the Double Duct Sign: Not Always A Harbinger of Malignancy
  1. Tate Hodges; RWJBH - Saint Barnabas Medical Center
  2. Michael Simon; RWJBH - Saint Barnabas Medical Center
  3. Bruce Carpenter; RWJBH - Saint Barnabas Medical Center
  4. Daniel Garnet; RWJBH - Saint Barnabas Medical Center
The double duct sign is a radiologic sign first described in 1976 by Freeny et al. on endoscopic retrograde cholangiopancreatography (ERCP).(1) The sign describes the combined presence of a dilated common bile duct (CBD) and pancreatic duct.(2) This sign is considered a “hallmark sign” of pancreatic head ductal adenocarcinoma when identified on magnetic resonance cholangiopancreatography (MRCP) or computed tomography (CT).(3) In patients who present with jaundice, the presence of the double duct sign was found to be biopsy proven malignancy in 85% of cases.(4) Rapid, conclusive diagnosis for pancreatic cancer is paramount as even brief delays can quickly progress to unresectable disease. However, despite being classically considered a ‘hallmark’ of malignancy, it is crucial to recognize benign causes of this finding such as chronic pancreatitis, atypical autoimmune pancreatitis or chronic stone disease.(5) These benign etiologies further complicate diagnosis and can lead to unnecessary interventions. We present a patient with painless jaundice who on initial presentation was found to have the double duct sign on abdominal CT. Endoscopic and open biopsy was performed which confirmed chronic pancreatitis.

Educational Goals / Teaching Points
It is classically taught that the double duct sign, especially in the context of painless jaundice or unintentional weight loss, is strongly suggestive of a pancreatic head neoplasm. However, in this scenario, it is crucial for the radiologist to communicate to the clinician that these concerning clinical and imaging findings may not necessarily be indicative of a malignant process. Avoiding unnecessary, invasive interventions and unwarranted patient anxiety would be a direct benefit.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
Initial imaging typically includes abdominal CT, followed by MRI/MRCP. An EUS/ERCP is often then performed for diagnosis and biopsy. There are multiple etiologies of this imaging finding including stenosis, stricture or obstruction within the head of the pancreas.(4)

Although the double duct sign is often associated with malignancy, benign etiologies are possible. It is important to differentiate these causes in a relatively rapid manner as the management is vastly different. Accurate diagnosis is imperative in preventing severe morbidity.