Sanjeeb Kumar Sarma (Down Town Hospital / Guwahati / India)  

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10 Years  

Male  

Abdomen-Liver  

congenital  

10 years old male patient complains of on and off right upper abdominal pain since last 3-4 months.  

Congenital dilatation of the biliary tract, so called choledochal cyst, is classified based on spectrum of morphologic changes in the bile ducts. The most common classification scheme of Alonso-Lej includes type I, which is dilatation of the CBD; type II, which is diverticulum of the CBD; and type III, which is a rare choledochocele. Todani and his colleagues further added to this classification type IV-A, representing multiple cysts of the IHBDs and EHBDs; type IV-B, representing multiple cysts of EHBDs; and type V, representing multiple cysts of the IHBDs , or Caroli disease.
The choledochal cyst is not a true cyst of the biliary tract but rather some variation of duct dilatation. Etiology is unknown but supposedly multifactorial.
On CT choledochal cyst can have varying appearance depending on the extent of ductal involvement and the degree of dilatation. There may only be mild EHBD dilatation or a large water density mass in porta hepatis or adjacent to the head of the pancreas.Reportedly, 60% of choledochal cyst will have associated congenital IHBD dilatation..Congenitally dilated IHBD often have a lobulated cystic appearance with an abrupt transition zone at the junction with the normal ducts.Acquired biliary dilatation usually doesn't have the lobulated cystic appearance and the dilated ducts usually taper gradually towards the periphery of the liver.Direct communication of the cystic duct to the dilated EHBDs will aid making the diagnosis of choledochal cyst.Ultrasonography aids to differentiate with other pathology.However, sometimes DISIDA scan may be required. CT and MR cholangiography are diagnostic.
Here, is a case of type I disease with tiny calculi both within gall bladder and choledochal cyst.  

<- view MRI 1

MRI 1: Axial T2 sections showing dilated CBD with intraluminal sludge and calculi.





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MRI 2: Axial T2 sections showing multiple small calculi in gall bladder neck (arrow).





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MRI 3: Axial T2 sections showing gall bladder ( short arrow) and a cystic structure (long arrow)





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MRI 4: Axial T2 sections showing a cystic structure with luminal sludge and the gall bladder.





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MRI 5: Axial T2 sections showing dilated CBD anterior to IVC.




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MRI 6: MRCP showing gall bladder with calculi (short arrow) and a cystic structure (long arrow).





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MRI 7: MRCP showing both gall bladder and a cystic structure.





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MRI 8: MRCP showing small calculi in a cystic structure (arrow)



 

Imaging including endoscopy  

Gastro-intestinal tract duplication cyst, mesenteric cyst, hepatic cysts, pseudocysts, ovarian cysts, and renal cysts.  

If untreated bile stasis, stone formation,infection , pancreatitis,biliary cirrhosis, and portal hypertension may occur.Reported increased incidence of hepatobiliary malignancy.  

Surgical treatment was done with improvement and follow up is done on regular basis.  

N/A  

1. Medline:
1.Computed tomography and magnetic resonence imaging of the whole body by John R Haaga, Charles F Lanzeri--4th Ed.Mosby 3003.  

Choledochal, choledochocele, IHBD, EHBD, CBD., child, childhood, pediatric radiology  

Sanjeeb Kumar. Choledochal cyst. PedRad [serial online] vol 9, no. 12.
URL: www.PedRad.info/?search=20091226123802