A giant choledochal cyst: A case reported from Tanzania

Infantile choledochal cyst presenting with an epigastric bilioma: An iceberg phenomenon

INTRODUCTION

Choledochal cysts (CC) are rare congenital biliary dilatations that are capable of presenting with a gamut of clinical findings. Perforation, a rather rare presentation, can account for 1.8-7% of cases. In an infant with non-specific abdominal complaints and a vaguely palpable upper abdominal mass, a perforated CC may be overlooked, leading to a delayed or misdiagnosis and a detrimental outcome.

CASE PRESENTATION

We describe a 10-month-old girl who presented to the office with upper abdominal pain and associated fullness for two weeks. An abdominal ultrasonogram revealed perihepatic collections and an evident dilatation of the common bile duct. The bile aspirated from the collections prompted pigtail drainage as an emergency. Magnetic resonance cholangiopancreatography later revealed a spontaneously perforated CC with residual bilioma. Elective resection after six weeks, followed by bilio-enteric reconstruction, resulted in an uneventful recovery.

CLINICAL DISCUSSION

Biliary peritonitis and localized biliomas are rare forms among the wide range of findings that can accompany CC. Satisfactory outcomes can be achieved with a two-stage procedure that entails biliary drainage with sepsis control, followed by resection of the CC and bilio-enteric reconstruction a few weeks later.

CONCLUSION

It is important to be aware of the spectrum of findings that CC may present. We discussed our experience successfully treating a perforated type IVa CC.

Giant choledochal cyst: The largest reported!

Choledochal cyst (CC) is an atypical congenital abnormality of the biliary system. CC more than 10 cm is rare and only a few cases are reported. Herein, we reported a 25 × 18 cm CC and highlighted how definitive treatment after a timely diagnosis provides good prognosis irrespective of the size.

Choledochal cyst type I with dilated intrahepatic biliary radicles: a type IVA mimic

Background

A choledochal cyst is a relatively rare congenital anomaly of the biliary tree requiring surgery as the definitive treatment. Amongst the five Todani variants, type I poses a diagnostic and treatment challenge owing to its infrequent, yet clinically significant mimicry for type IVA cysts.

Case presentation

We present a case of a 4-year-old female diagnosed to have a giant type IA choledochal cyst that mimicked a type IVA cyst on radiological imaging. The patient was treated by complete cyst excision, cholecystectomy, and restoration of the biliary-enteric communication by a Roux-en-Y hepaticojejunostomy. Regression of the dilated intrahepatic radicles that counterfeited a type IVA cyst was confirmed on follow-up imaging studies.

Conclusion

Such an encounter, although rare, can significantly alter the course of management. We recommend extrahepatic cyst excision with biliary reconstruction as the standard treatment when preoperative and intraoperative imaging studies fall short in differentiating the aforementioned variants.

Imaging diagnosis of a giant choledochal cyst in an infant

The usual etiologies of giant abdominal cystic masses in infants are mesenteric cyst, enteric duplication cyst, ovarian cyst in females, cystic lymphangioma, however, the presentation of a choledochal cyst in a gigantic form, is unusual. The primary modality for diagnosis of this entity is ultrasound, followed by MRI. The characteristic ultrasound features of a choledochal cyst are a well-defined cystic lesion which may be found to replace any segment of the biliary tree and is distinctly separate from the gallbladder. The associated anomalies are biliary atresia, gallbladder atresia, hepatic fibrosis and those of the pancreatico-biliary ductal system. MRI with MRCP has a conclusive role in confirming the ultrasound diagnosis. Choledochal cysts are currently classified as proposed by Todani et al, into five types. Herein, we report the case study of a 4-month-old male infant afflicted with a gigantic, Type1 Choledochal cyst, complicated by perforation, which was diagnosed by us at the first instance itself, using ultrasound examination and confirmed by MRI. The diagnosis was further confirmed at surgery and histopathology. The recommended treatment of cyst resection accompanied by a hepatico-jejunostomy bypass procedure, was successfully performed in the reported infant.