Choledochocele: an unusual type of choledochal cyst which presented as acute pancreatitis

JPN Guidelines for the management of acute pancreatitis: epidemiology, etiology, natural history, and outcome predictors in acute pancreatitis

Acute pancreatitis is a common disease with an annual incidence of between 5 and 80 people per 100 000 of the population. The two major etiological factors responsible for acute pancreatitis are alcohol and cholelithiasis (gallstones). The proportion of patients with pancreatitis caused by alcohol or gallstones varies markedly in different countries and regions. The incidence of acute alcoholic pancreatitis is considered to be associated with high alcohol consumption. Although the incidence of alcoholic pancreatitis is much higher in men than in women, there is no difference in sexes in the risk involved after adjusting for alcohol intake. Other risk factors include endoscopic retrograde cholangiopancreatography, surgery, therapeutic drugs, HIV infection, hyperlipidemia, and biliary tract anomalies. Idiopathic acute pancreatitis is defined as acute pancreatitis in which the etiological factor cannot be specified. However, several studies have suggested that this entity includes cases caused by other specific disorders such as microlithiasis. Acute pancreatitis is a potentially fatal disease with an overall mortality of 2.1%–7.8%. The outcome of acute pancreatitis is determined by two factors that reflect the severity of the illness: organ failure and pancreatic necrosis. About half of the deaths in patients with acute pancreatitis occur within the first 1–2 weeks and are mainly attributable to multiple organ dysfunction syndrome (MODS). Depending on patient selection, necrotizing pancreatitis develops in approximately 10%–20% of patients and the mortality is high, ranging from 14% to 25% of these patients. Infected pancreatic necrosis develops in 30%–40% of patients with necrotizing pancreatitis and the incidence of MODS in such patients is high. The recurrence rate of acute pancreatitis is relatively high: almost half the patients with acute alcoholic pancreatitis experience a recurrence. When the gallstones are not treated, the risk of recurrence in gallstone pancreatitis ranges from 32% to 61%. After recovering from acute pancreatitis, about one-third to one-half of acute pancreatitis patients develop functional disorders, such as diabetes mellitus and fatty stool; the incidence of chronic pancreatitis after acute pancreatitis ranges from 3% to 13%. Nevertheless, many reports have shown that most patients who recover from acute pancreatitis regain good general health and return to their usual daily routine. Some authors have emphasized that endocrine function disorders are a common complication after severe acute pancreatitis has been treated by pancreatic resection.

Choledochocele: importance of histological evaluation

Choledochocele is a rare abnormality of unknown etiology that consists of cystic or diverticular dilatations of the intramural part of the common bile duct. The authors present a case of choledochocele with a common channel in a 15-year-old boy who had a 5-year history of intermittent right upper abdominal pain. In a review of the literature, macroscopic variations were noted as well as different types of epithelial lining inside the choledochocele. Whereas in young children mostly duodenal mucosa is described, biliary tract epithelium and undifferentiated epithelium are predominant later on. Etiologically, congenital intraluminal duodenal diverticulum should be suggested in relation to the pathogenesis of choledochocele. Treatment is total excision and reinsertion of both ducts in cases of biliary or undifferentiated epithelium; endoscopic sphincterotomy or marsupialization is indicated only when duodenal mucosa covers both sides of the choledochocele.

Choledochocele and recurrent pancreatitis. Diagnosis and surgical management

A case history has been presented that reports a rare type III choledochal cyst (choledochocele) and describes the association of a choledochocele and recurrent acute pancreatitis. The most reliable diagnostic technique, as used in our patient and supported by our literature review, is endoscopic retrograde cholangiopancreatography. This case further supports surgical correction employing transduodenal sphincteroplasty. This procedure is highly recommended for management of the intramural choledochocele (type IIIc), especially when associated with recurrent pancreatitis. Finally, patients who present with recurrent pancreatitis without the usual historical or diagnostic findings of biliary tract or alcoholic disease should have a choledochocele included in the differential diagnosis.

Choledochocele: report of a case and review of the literatures

A case of choledochocele seen in a 68-year-old male was reported. Analysis of fourteen cases reported under a variety of designations featuring cystic dilatation of the distal common bile duct protruding into the duodenal lumen and the case presented here disclosed that these cases could be classified into two types of pathology; both of the bile duct and the pancreatic duct opened into the cyst of the ampulla in 6 cases, whereas the bile duct and the pancreatic duct joined at the papilla of Vater and distal end of the bile duct formed a cystic dilatation protruding into the duodenal lumen in the remaining 9 cases.

Choledochocele demonstrated on percutaneous cholangiography: a patient with acute fulminant pancreatitis

A patient with a choledochocele associated with development of acute fulminant pancreatitis is presented. Treatment had been severely compromised by this rare anomaly before it was identified by percutaneous cholangiography. Because it is potentially curable with surgery, identification of the lesion by percutaneous or intravenous cholangiography has important clinical significance.

Choledochocele of the common bile duct

The eighth report case of choledochocele is described. This lesion is a cyst communicating with the terminal portion of the common bile duct. It is characteristically lined with duodenal mucosa and is probably a form of duplication of the duodenum. The surgical treatment is marsupialization of the cyst to the interior of the duodenum.