Cystic duct diverticulum

Case contributed by Dr Gaurav Som Prakash Gupta

Presentation

Acute abdomen-- Right hypochondrium pain and vomitting.

Patient Data

Age: 55
Gender: Male
Modality: MRI
The gall bladder is distended and shows evidence of T2 hyperntense sludge and bile. There is evidence of dependently located multiple signal voids. This signal void shows mobility with movement towards dependent portion of the gall bladder while scanning with prone position -thus confirming gall bladder calculi. Largest of these calculi measure upto 10mm to 12mm.
The wall of GB is markedly thickened measures upto 8mm to 13mm. 
There is evidence of multiple linear intramural T2 hypointense foci within the gall bladder lumen which are likely to be indicating intramural herniation of the gall bladder mucosa (Rokitansky-Aschoff sinuses) - suggestive of diffuse adenomyomatosis of the gall bladder (also confirmed and correlated with ultrasound).
CBD measures 5.2mm and shows normal gradual distal tapering. The common bile duct appears normal in calibre and the confluence of the right and left hepatic ducts is seen normally. The intrahepatic biliary radicles appear normal in calibre. 
The pancreatic duct show normal configuration and appearance and is joining CBD before opening into ampulla Vator.
The proximal cystic duct is normal in calibre; however, there is evidence of fusiform dilatation of the mid portion of cystic duct where it measure upto 24mm. The distal cystic duct is normal in calibre and is opening into CBD roughly at 7 o'clock position. A vessel is seen crossing the cystic duct at the level of the distal transition of the dilated portion of cystic duct into normal mucosa.
There is evidence of very minimal peri-cholecystic fluid. 
Peripancreatic fat planes are normal. 
The opposite phase imaging reveals diffuse fatty infiltration of liver.
IMPRESSION: -
MR findings are consistent with -
Cholelithiasis with acute cholecystitis with status as described above.
Fusiform diverticulum like dilatation of the mid portion of cyst duct is noted with features as described -suggestive of cystic duct diverticulum.
Clinical correlation is recommended.

Case Discussion

This case shows  features of Adenomyomotosis of GB and its MRCP apperance.

The case also demonstrate all the features of the Acute Choelcystitis and choelelithiases as seen in MRCP.

There is a evidence of fusifrom type of cystic duct diverticulum.

The Tdani's classifcation describes only 5 type of Choledochal cyst Abnormality. The diverticulum  dilatation of the Cystic duct has not been described by Todani. However, there are some sporadic case reports and a series of 10 cases  of this entity. The significance of this entity is in surgical planing. Allowing a preoperative diagnosis of this condition may warn the surgeon and avoid potential complications. There may be other long term significance of this condition, however, this needs to be investigated by appropriate studies.

PlayAdd to Share

Case Information

rID: 24143
Case created: 29th Jul 2013
Last edited: 18th Dec 2015
Inclusion in quiz mode: Included

Updating… Please wait.
Loadinganimation

Alert accept

Error Unable to process the form. Check for errors and try again.

Alert accept Thank you for updating your details.