Pediatric types I and VI choledochal cysts complicated with acute pancreatitis and spontaneous perforation: A case report and literature review

A nomogram for predicting choledochal cyst with perforation

BACKGROUND

Choledochal cyst with perforation (CC with perforation) rarely occurs, early diagnosis and timely treatment plan are crucial for the treatment of CC with perforation. This study aims to forecast the occurrence of CC with perforation.

METHODS

All 1111 patients were conducted, who underwent surgery for choledochal cyst at our hospital from January 2011 to October 2022. We conducted univariate and multivariate logistic regression analysis to screen for independent predictive factors for predicting CC with perforation, upon which established a nomogram. The predictive performance of the nomogram was evaluated using receiver operating characteristic (ROC) curves, calibration plots, and decision curve analysis (DCA) curves.

RESULTS

The age of children with choledochal cyst perforation is mainly concentrated between 1 and 3 years old. Logistic regression analysis indicates that age, alanine aminotransferase, glutamyl transpeptidase, C-reactive protein, vomiting, jaundice, abdominal distension, and diarrhea are associated with predicting the occurrence of choledochal cyst perforation. ROC curves, calibration plots, and DCA curve analysis curves demonstrate that the nomogram has great discriminative ability and calibration, as well as significant clinical utility.

CONCLUSION

The age of CC with perforation is mainly concentrated between 1 and 3 years old. A nomogram for predicting the perforation of choledochal cyst was established.

Comparison of Clinical and Radiologic Findings Between Perforated and Non-Perforated Choledochal Cysts in Children

OBJECTIVE

To compare the clinical and radiologic findings between perforated and non-perforated choledochal cysts in children.

MATERIALS AND METHODS

Fourteen patients (mean age ± standard deviation, 1.7 ± 1.2 years) with perforated choledochal cysts (perforated group) and 204 patients (3.6 ± 3.8 years) with non-perforated choledochal cysts (non-perforated group) were included between 2000 and 2019. All patients underwent choledochal cyst excision after ultrasound, CT, or MR cholangiopancreatography. Relevant data including demographics, clinical symptoms, laboratory findings, imaging findings, and outcomes were analyzed. Statistical differences were compared using the Mann-Whitney U test and Fisher's exact test.

RESULTS

Choledochal cyst perforation occurred only in children under the age of 4 years. Acute symptoms, including fever (p < 0.001), were more common in the perforated group than in the non-perforated group. High levels of white blood cells (p = 0.004), C-reactive protein (p < 0.001), and serum amylase (p = 0.002), and low levels of albumin (p < 0.001) were significantly associated with the perforated group. All 14 patients with perforated choledochal cysts had ascites, whereas only 16% (33/204) of patients in the non-perforated group had ascites (p < 0.001). In the subgroup of patients who had ascites, a large amount of ascites (p = 0.001), increase in the amount of ascites in a short time (p < 0.001), complex ascites (p < 0.001), and perihepatic pseudocysts (p < 0.001) were more common in the perforated group than in the non-perforated group.

CONCLUSION

Children with perforated choledochal cysts have characteristic clinical and radiologic findings compared to those with non-perforated choledochal cysts. In young children with choledochal cysts, perforation should be differentiated in cases with acute symptoms, laboratory abnormalities, and characteristic ascites findings.

Value of serum GGT level in the timing of diagnosis of choledochal cyst perforation

BACKGROUND

Choledochal cyst perforation is extremely rare, and early diagnosis or prediction is important for the immediate therapeutic intervention of perforations. This study aimed to define the predictor(s) of an impending or complete spontaneous perforation of choledochal cyst and establish the optimal operative timing.

METHODS

All 429 consecutive choledochal cyst patients from January 2015 to December 2021, were included. A retrospective study was performed based on Kaplan-Meier analysis, and Cox univariate and multivariate analyses.

RESULTS

A total of 429 patients were included, among which, 21 had choledochal cyst perforations (group A), and 408 did not (group B). Compared to group B, the serum alanine aminotransferase, aspartate aminotransferase, direct bilirubin, gamma-glutamyl transpeptidase, indirect bilirubin, total bilirubin, and alkaline phosphatase were significantly higher in group A (p = 0.025, 0.006, < 0.0001, 0.0001, 0.001, < 0.0001, and 0.033). High serum gamma-glutamyl transpeptidase was negatively associated with perforation-free preoperative survival, and multivariate Cox regression revealed that serum gamma-glutamyl transpeptidase was an independent predictive factor for an impending or complete perforation (p = 0.042).

CONCLUSIONS

A gamma-glutamyl transpeptidase level ≥ 346.5 U/L accompanied with significantly elevated liver enzymes and bilirubin levels was indicative of the possibility of an impending or complete choledochal cyst perforation, and a proactive surgical approach should be considered.

Value of Ultrasound in Diagnosing Perforation of Congenital Choledochal Cysts in Children

OBJECTIVES

This study aimed to investigate the diagnostic value of ultrasound in children with perforation of congenital choledochal cysts.

METHODS

Eligible patients recruited from January 2004 to December 2018 in our hospital were enrolled in this retrospective study. A total of 59 cases of congenital choledochal cysts with perforation were defined as the perforation group, and 100 cases of congenital choledochal cysts without perforation with similar symptoms were defined as the control group. Clinical features were analyzed and compared between the groups. The differential efficacy of varied diagnostic criteria was evaluated by a receiver operating characteristic analysis.

RESULTS

Significant differences were found between the groups with respect to clinical characteristics (abdominal pain, vomiting, fever, and abdominal distention; all P < .01) and the disease onset age (P < .001), but the diagnostic efficacy of both was poor (both areas under the curve, <0.7). The interruption of bile duct continuity only occurred in the perforation group with high specificity of 100% but poor sensitivity of 18.6%. The discrimination of combined features was significantly better (area under the curve, 0.936) than that of the disease onset age and clinical characteristics, with observed sensitivity and specificity of 93.2% and 94.0%, respectively.

CONCLUSIONS

Using specific features, ultrasound can effectively diagnose perforation of a congenital choledochal cyst in children.

Influence of Xuebijing injection combined with cefoperazone sodium and sulbactam sodium in treating hepatitis B-induced liver cirrhosis complicated by spontaneous bacterial peritonitis: TNF-α, IL-18, IL-6, and hepatic function

OBJECTIVE

To analyze the influences of Xuebijing injection combined with cefoperazone sodium and sulbactam sodium (CSSS) in the treatment of hepatitis B-induced liver cirrhosis (HBLC) complicated by spontaneous bacterial peritonitis (SBP) with respect to tumor necrosis factor-α (TNF-α), interleukin-18 (IL-18), interleukin-6 (IL-6), and hepatic function.

METHODS

A total of 98 patients with HBLC complicated by SBP admitted to our hospital were selected and divided into the control group (CON, n=49) and the observation group (OBG, n=49) in accordance with the therapeutic methods. The clinical data of the patients were retrospectively analyzed. The CON was treated with CSSS, while the OBG was treated with Xuebijing injection combined with CSSS. The time of symptomatic improvement and changes of serum inflammatory factors and indices of intestinal mucosal barrier damage and hepatic function were compared between the two groups before and after treatment.

RESULTS

The time of symptomatic improvement in the OBG was shorter than that in the CON (P < 0.05). After treatment, IL-6, IL-18, TNF-α, urinary L/M, D-lactic acid, DAO, total bilirubin, ALT, and AST in the OBG were lower than those in the CON (P < 0.05).

CONCLUSION

Xuebijing injection combined with CSSS is conducive to improving the inflammatory responses of the body, intestinal tract barrier function, and hepatic function, showing satisfactory efficacy in the treatment of HBLC complicated by SBP.