Gastroenterology
Volume 128, Issue 5 , Page 1159, May 2005

Image of the Month:

David M. Warshauer, Section Editor

  • Eitan Gross, MD

      Affiliations

    • Department of Pediatric Surgery
    • ,
  • Benjamin Z. Koplewitz, MD

      Affiliations

    • Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel

Article Outline

 

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Question 

A 12-year-old boy presented with recurrent epigastric abdominal pain without vomiting, jaundice, or weight loss, lasting for 6 months. Blood tests were normal except for slightly elevated liver function tests and amylase. Physical examination was not revealing. Abdominal sonography showed a cyst in the left upper abdomen. A computerized tomography scan of the abdomen following oral contrast administration was performed in a supine position (Figure A) and in a right lateral decubitus position (Figure B), and an upper gastrointestinal study (Figure C) was obtained.

What is the diagnosis?

Look on page 1536 for the answer and see the Gastroenterology website (http://www.gastrojournal.org) for more information on submitting your favorite image to Image of the Month.

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Answer to the Image of the Month Question (page 1159): Choledochocele Type 3 Choledochal Cyst 

The diagnosis in this case is choledochocele, which is a type 3 choledochal cyst. The computerized tomography scan performed following oral contrast administration in the supine position (Figure A) and in the right lateral decubitus position (Figure B) showed the cyst in different positions within the duodenal lumen, delineated by a thin peripheral layer of contrast medium. The upper gastrointestinal series (Figure C) revealed an intraluminal duodenal filling defect, which on fluoroscopy, moved from the second part of the duodenum into the proximal jejunum and back.

Laparotomy was performed. After opening the duodenum, a submucosal, 4-cm cystic mass with the papillae of Vater at its medial part was found (Figure D, c = choledochocele; p = Papilla of Vater.). The cyst was filled with clear bile. It was resected and pappiloplasty was performed. Pathological examination of the cyst was compatible with choledochocele, which is a type 3 choledochal cyst.

Choledochal cyst is a rare congenital dilatation of the bile ducts. The cause of choledochal cyst is unclear. The most widely used classification of these cysts is Todani’s classification.1 Type 3 choledochal cyst, as in our patient, is an intraduodenal common bile duct dilatation, and is less commonly encountered. Symptoms usually present during the first decade of life. Although jaundice prevails in early childhood, abdominal pain is the presenting symptom in adolescents and adults.2

Other symptoms and signs include: nausea, vomiting, palpable mass, pancreatitis, or cholangitis. The classic triad of abdominal pain, jaundice, and a palpable mass is uncommon. The appropriate treatment of a choledochal cyst is surgical resection and not internal drainage, because it has been shown that cholangiocarcinoma may develop in the retained cyst wall.3

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References 

  1. Todani T , Watanabe Y , Narusue M , Tabuchi K , Okajima K . Congenital bile duct cysts, classification, operative procedures, and review of thirty-seven cases including cancer arising from choledochal cyst . Am J Surg . 1977;134:263–269
  2. De Vries JS, De Vries S, Aronson DC, Bosman DK, Rauws EAJ, Bosma A, et al. Choledochal cysts: age of presentation, symptoms, and late complications related to Todani’s classification . J Pediatr Surg . 2002;37:1568–1573
  3. Todani T , Toki A . Cancer arising in choledochal cyst and management . Nippon Geka Gakkai Zasshi . 1996;97:594–598

 For submission instructions, please see the Gastroenterology website (http://www.gastrojournal.org).

PII: S0016-5085(05)00578-0

doi:10.1053/j.gastro.2004.08.069

Gastroenterology
Volume 128, Issue 5 , Page 1159, May 2005

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