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| LETTER TO EDITOR |
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| Year : 2018 | Volume
: 5
| Issue : 2 | Page : 165-166 |
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Multimodality imaging of choledochal cyst
Reddy Ravikanth1, Pooja Majumdar2
1 Department of Radiology, St. John's Medical College, Bangalore, Karnataka, India
2 Department of Medicine, INHS Sanjeevani, Kochi, Kerala, India
| Date of Web Publication | 9-Apr-2018 |
Correspondence Address:
Reddy Ravikanth
Department of Radiology, St. John's Medical College, Bangalore, Karnataka
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/cjhr.cjhr_85_17
How to cite this article:
Ravikanth R, Majumdar P. Multimodality imaging of choledochal cyst. CHRISMED J Health Res 2018;5:165-6 |
Sir,
A 27-year-old young female with a history of nausea, vomiting, jaundice, and chronic abdominal pain for 2 years presented to the emergency department. On examination, vitals were stable. Right hypochondrial and epigastric tenderness were elicited with organomegaly. Hematological investigations revealed direct bilirubin 18 mg/dl (normal direct bilirubin: <0.3 mg/dL), total bilirubin 24 mg/dl (normal total bilirubin: 0.1 to 1.2 mg/dl), serum amylase 946 U/L (normal serum amylase: 40–140 U/L), and serum lipase 1402 U/L (normal serum lipase: 0–50 U/L). Imaging workup included an initial screening transabdominal ultrasound and multidetector computed tomography (MDCT) abdomen which showed hepatomegaly, dilatation of the right and left hepatic ducts and their branches with fusiform dilatation of the common bile duct (CBD) [Figure 1] and [Figure 2]. However, no calculi were noted in the dilated biliary tree. The pancreas was bulky and edematous with surrounding inflammatory fat stranding. This was followed by magnetic resonance cholangiopancreatography (MRCP) 2 days later. Multisequence MRCP images of the pancreaticobiliary system with appropriate fat suppression were acquired which showed dilatation of the intrahepatic and extrahepatic biliary tree with focal stenosis distal to the biliary confluence and the distal CBD with associated dilatation of the cystic duct which was diagnosed as Type IV-A choledochal cyst [Figure 3]. Gallbladder was seen to be contracted with no filling defects in the biliary system. Percutaneous biliary drainage was safely performed in this patient. | Figure 1: Upper abdominal transverse view at the level of biliary confluence and pancreas on transabdominal ultrasonography showing dilatation of the left and right hepatic ducts with fusiform dilatation of the common bile duct
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 | Figure 2: Axial plain multidetector computed tomography image showing dilatation of the left and right hepatic ducts and their branches
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 | Figure 3: Coronal three-dimensional magnetic resonance cholangiopancreatography image showing Type IV choledochal cyst showing dilatation of the intrahepatic and extrahepatic biliary tree with fusiform dilatation of the proximal and mid common bile duct. Contracted gallbladder is seen in the image
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Choledochal cysts are a congenital anomaly, and they show dilatation of the intrahepatic or extrahepatic biliary tree. Choledochal cysts are classified into five groups based on the location of shape of the cysts. Choledochal cysts arise due to regurgitation of the pancreatic juice into the CBD, leading to inflammation, epithelial denudation, and weakness of the bile duct wall eventually leading to cyst formation. The role of imaging in the evaluation of choledochal cyst is to delineate the anatomy of the cyst, determine the relationship of the cyst to the rest of the intrahepatic and extrahepatic biliary tree, evaluate associated complications, and biliary tree abnormalities. Sonography is useful in assessing the full extent of biliary duct dilatation and for identifying the communication between the cyst and the biliary tree as seen in this case. It can also demonstrate the presence of calculi, stricture, or tumor if present. On CT and magnetic resonance imaging, a choledochal cyst appears as a right upper quadrant, fluid-filled structure in contiguity with the extrahepatic bile duct. Multimodality imaging with ultrasound, MDCT, and MRCP increases the diagnostic accuracy of choledochal cysts and its complications such as cholecystitis, recurrent cholangitis, biliary stenosis, choledocholithiasis, recurrent acute pancreatitis, and malignant transformation into cholangiocarcinoma. According to Todani et al.'s classification of choledochal cysts, Type IV cysts show dilatation of either the intrahepatic or extrahepatic biliary duct or both. The Type IV cyst is the second most common type in adults and represents 10%–15% of adult cases.[1] MRCP is a useful, non-invasive tool which shows good overall accuracy in the detection and classification of choledochal cysts. MRCP can simultaneously delineate both biliary and pancreatic duct structures whereas ERCP may fail to delineate these structures in patients with choledochal cysts due to the possibility of tight stricture in the distal portion of the cyst. MRCP may be a superior diagnostic tool over ERCP for patients with choledochal cysts.[2] Cyst remnants lead to malignant transformation of the cyst wall. Surgical procedure without cyst excision does not diminish malignant potential.[3]
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | |  |
| 1. | Weyant MJ, Maluccio MA, Bertagnolli MM, Daly JM. Choledochal cysts in adults: A report of two cases and review of the literature. Am J Gastroenterol 1998;93:2580-3.  |
| 2. | Park DH, Kim MH, Lee SK, Lee SS, Choi JS, Lee YS, et al. Can MRCP replace the diagnostic role of ERCP for patients with choledochal cysts? Gastrointest Endosc 2005;62:360-6. |
| 3. | Mabrut JY, Bozio G, Hubert C, Gigot JF. Management of congenital bile duct cysts. Dig Surg 2010;27:12-8. |
[Figure 1], [Figure 2], [Figure 3]
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