Choledocholithiasis and choledochal cyst

Case contributed by Dr Matt Dentry

Presentation

The patient presented with 1 week of constant right upper quadrant pain, anorexia and fevers. The examination was Murphy's positive. WCC 6 x 10(9)/L, deranged LFT, normal lipase and CRP 60 mg/L

Patient Data

Age: 25 years
Gender: Female
Ultrasound

Abdomen

Grossly distended gallbladder with thin wall and probe tenderness. Gall stones are noted in the grossly distended bile duct suggestive of choledocholithiasis within choledochal cyst (type 1).

CT

Abdomen

Distal CBD with choledocholithiasis. Mild pericholecystic stranding consistent with acute cholecystitis. Marked focal dilation of the common bile duct, containing multiple gallstones. The common bile duct between the focally dilated segment and distal CBD stone is non-dilated. Appearances are suggestive of a type I choledochal cyst.

Fluoroscopy

Intraoperative II

Intraoperative II of removal the choledocholithiasis from the CBD with before and after images.

CT

CT cholangiogram

CT cholangiogram (post-Biliscopin)  

The common hepatic and common bile duct show fusiform dilatation, involving almost its entire length. Maximum diameter measures approximately 3.7x3.4cm on the axial plane.  There are few small focal outpouchings seen along the left wall of this dilated CBD. Overall findings are in keeping with a type 4A choledochal cyst by Todani classification

No obvious residual calculi identified. No leakage was seen.

Case Discussion

The patient presented with signs and symptoms consistent with cholelithiasis. Bloods indicated an obstructed picture. Ultrasound showed cholecystitis with choledocholithiasis in the setting of type 1 choledochal cyst. This was confirmed on follow up CT abdomen.

The patient progressed to an open cholecystectomy with bile duct clearance via open and choledochoscope. No leak was demonstrated and the wound was closed with a drain left in situ. She had increasing pain several days later. Unfortunately, she was unable to have MRCP as an unknown metal foreign body was in situ from overseas. 

The decision was made to progress to a CT cholangiogram. This showed no leak or residual stone. There was contrast seen progressing into the duodenum. Dilation of the intrahepatic bile duct changed the choledochal cyst from type 1 to a type 4A. 

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Case information

rID: 79452
Published: 18th Jul 2020
Last edited: 18th Jul 2020
Inclusion in quiz mode: Included

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